1984, 05-25 Permit App: 0000335 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)
(first) (m) IJ iOnIy
(Department
1 Owner's Name (fast)
I436.
--V A( (&/• .7
COMM
.7,4 C' Space Zip
2 Project Address (not Mailing Address) cr Road Nam
..3(2)3 iia/ 95'2- /e
3 City/Communit_ y
State
Subdivision/PPj''t ame ,
4 r Parcel No.
Lot
Block
,----.
* * * DEPARTMENT USE ONLY * * *
5 Sic Oode
Zone Act. 0
Zone
/k
,J
Project No. ✓
,
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bads -Front
(L)S-1
(R)S-2
I Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
I
Street Address
,-).- *S----a---e-erv-,
Zip
2.L >
City
'-L-
State
hJ4`- -
Phone
( ) 2-3,c — 29 g f
Pqrson
Phone if different than above
Contractor Firm Name
Street
/y(
Address
-Q.( /.
--1,,--- 6,-
. ,
Zip
?42 6
qty
State
.
Phone
( ) ,•4-Y— 6 7/ 6
Contac Per
License No. tOZ7�Q
Phone If different than above
r 8 Owner/Agent (if different than 01 above)
Business Address
' 9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) I
1.0 c,
SEPA Exempt (Y/N)
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
B" New
❑ Add/ Alter
E Replace
❑ Move
❑ Other
14 Describe Wo
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
�j
O
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
APPLICATION #
Conditions/ Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone; '
O CU, variance, zone change; shoreline; ❑ fence; �J
O Other p%/r
Conditions/Comments./1954-
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments.
1/ Utilities:
N. 81-1 Jefferson
0 Flood Plain;
0 fence;
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments •
Information
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
Release
Release
w/cond 1
Hold 2
Conditions/ Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone; '
O CU, variance, zone change; shoreline; ❑ fence; �J
O Other p%/r
Conditions/Comments./1954-
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments.
1/ Utilities:
N. 81-1 Jefferson
0 Flood Plain;
0 fence;
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments •
Information
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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