1984, 07-25 Permit App: 00001445 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
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*
1Ow er's Na (last) (first) (m)
L I
Department lJee Only
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2 Project Address (not Mailing Address) or Road Name Space Zip
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3 City/Community
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State
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Subdivision !Plat Name j� d /
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On
���,Assessor Parcel No.
Lot
Block
* * * DEPARTMENT USE ONLY
Project No.1 .4 .1
5 Sic Code
Zone Act. #
Zone
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth _
1 7 Set Bads -Front (L S-1
2.3
(R)S-2
(5
Rear
l
Census Tract
Module No.
Initials
16 Architect Firm Name
f Street Address
fl
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name c--
1. , C. Y 4s -cc, AIrS -7
Street Address
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Zip
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City
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State
(i)c._
Phone
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{ Contact Person
G; i f t CYrf : it—�t
License �lo.
Phone if diff rent than above
( )
8 Owner/Agent (if different than #1 above)
S14,1�.
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
I SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
>rNNew
❑ Add/Alter
❑ Replace
❑ Move
D Other
14 Describe Work
S 111
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10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Leder
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Street Address
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Zip (} /!
City
State
Phone
Contact Person
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Phone if different than above
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Additional Information
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TECCIVE"=,�
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JUL51984
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E C E I V E =..
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Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
•
Release
Release w/cond 1
Hold 2
APPLICATION #
Conditions/Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; 0 Residential; ❑ Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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