1984, 06-11 Permit App: 00000622 Residneceves BUILDING 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)
1 Owner's Name (last) (first) (m)
(1). e, S 4_ K_,,,,,.)..,,,4, �"7 C- •.
Department Use
Fbs. Comm
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2 Project Address (not Mailing Address) or Road Name Space Zip
.3 3 14 S° in 'I l i ss ue DIE
3 City/Community
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State
cum .
Subdivision/ Plat Name /
l 1 r d aC , -(-1 . /
4 Assessor Parcel No.
Lot
4-
Block
/
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. M
Zone � - 4L
Project No. ^l
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth `
Frontage ,
7 Set Back -Front (
(L S-1
1L
(R)S-2
14
Rear ,
��
census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
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Street A ess
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Zip
99 V/
City
--3/70 ��11 �'
State
�.
Phone
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License -No.
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Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
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Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN)
I SEPA Exempt (Y/N)
Date
15 Type Work 1< Bldg
❑ Fire
❑ MH
❑ Demo
tg, New
0 Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work -�
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10 Applicant Name yJ �es ,----2:11C-Street
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11 Zip
(
�2� �_
State
�� .
- Phone
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ender
Street Address ./ /�
Zip
cj( City
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State
(de.
Phone
(S09 9 2._ z_ - / 2._ 0
ontact Person /
/J3.�h / fEA' V 0/7A7SO 01 -
Phone if different than above
( )
Additional Information
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541-5 eP5m
...----
144C1)
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Gil.e.._ 4 on 6 /2-17
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DEPARTMENT APPROVALS
0
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
This is not a Permit
•
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
•
Early Start
J
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; l�J sidential; El Flood Plain;
N. 811 Jefferson ❑ drainage new access/approach; ❑ fence;
i; -_.5-:-$y
I
❑ road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/ Comments*
Other:
Plan Exam 7
Fire Prey. ///
//
Conditions/Comments•
Project Representative Telephone
Agencies Performing Special Inspection:
1
iInformati
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
.7 V
•
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(
/,74)