1985, 02-14 Permit App: 00004180 ResidenceBUILDING PERMIT APPLICATION S F HOR E SHEET UNDERSTAND
T
PLEASE PRINT AND COMPLETE ONLY THOSE PAR
(Please return this original and your building plans to the Department of Building and Safety)
(m) Department Use Only
1. Owner's N= e
(last
2 Project Address (not Mailing Address) Name
33 /O S. k-5-5
3 CityICom sty
Assessor Parcel No. ��'° (uJ o�
100`
5 Sic Code
6 Dwell
7 Set Back -Front
Zone Act. #
3o'
No. of Buildings
(R)S-2
(L S-1
Lot
Zone
State tx.)
16 Architect Firm Name
Zip
9� Zo ci I tY--ioo/c-4-t,$)__
Contact Person
(first)
Block
Space
Zip
Comm
Subdivlsi• Plat Nape3/7Q/
i dC l g'�— //`'/
* * * DEPARTMENT USE ONLY * * *
Sq. Ft./Acre
Census Tract
Contractor Firm Name
Zip
Contact Person
City
State
Project No.
I SU
Depths r
Module No.
Frontage
Initials
1
Street Address ��
6u. 6'O G
Phon
9)-7y7_�767
Phone If different than above
IStreet Address
1 State Phone
License o. Phone If different than above
5ennii
1 Business Address
8 Owner/Agent (if different than #1 above)
9 Zip
{ City
12 Review Required
'Plan Check (YIN)
15 Type Work
14 Describe Work
State
Other (Y/N)
❑ Bldg ❑ MH �S( New
❑ Fire I ❑ Demo ElAdd/Alter
'20c- CQ- 01-#701),C_
IStreet Address
Phone
( )
SEPA Exempt (Y/N)
❑ Replace
❑ Move
10 Applicant Name
11 Zip
I City
Lender
I State
Zip
City
Contact Person
Additional Information
illi ' 74
1)12
upp
713
State
Date
0 Other
Phone
( )
IStreet Address
Phone
( )
Phone if different than above
( )
\
\�i
(,tt.=-1s4I)/
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application
This is not a Permit
•
Type
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Early Start
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/ Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments•
Engineers: ❑ Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson IDdrainage ❑ new access/approach; ❑ fence;
I
A
U road improvements
Conditions/Comments• /WA_ _ O3 /
tl I
Utilities:
N. 811 Jefferson
Conditions/Comments.
•
Other:
•
Plan Exam
Fire Prey.
,/
Conditions/Comments.
Project Representative Telephone
IInformation
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
865 ck ) MS(' /6) s rd AIWA_
3.510
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