1984, 10-25 Permit App: 00003010 Residence•
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)
rPartn�enOnly
3 e / e S.%tici 7T/GQ./ /4 s. Comm
2 Project Address (not Malting Addr ) or Road Name Space Zip
—) 35 /1 i / /5,5_4 r)r 10f0 6
3 City/Community (-_
-4'C LU1r e _
-6471L-11P-arcel
State
144- st4-/
Subdivision/Plat Name r
Mid, /U / / 0 4- L% / 1"/ o ,l-
No.
335 / 1 — _ 0.
Lot
Block
Z
* * * DEPARTMENT USE ONLY * * *
' 5 Sic Code
Zone Act. B
Zoner-e
Project No.
e ie
6 Dwell If /
No. of Buildings �
Sq. Ft./Acre � �i�
�f
Depth
Frontage
7 Set Back -Front
_ 35
(L S-1
26
(R)S-2
2 7
R
Census Tract
Module No.
Initials
9fx"
16 Architect Firm Name I
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City
I State
Phone
( )
Contact Person
License No. /
S %tSC,(e-S /77 !V/-
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
s
SEPA Exempt (Y/N)
Date
15 Type Work C��dg
❑ Fire
❑ MH
❑ Demo
i?JNew
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
h )/sicnit'C. 9(.(t6 Coe L/Arc/ev
10 Applicant Name i
7-e. fri/ Se. g e r c- -
Street Address
2 T / /1' / 74 G /7r m,p Cc,,,Le.e.
11 Zip
%/5)
City
6g4A,P Go, LQ.
State
5-71/---Z4.--4-
Phone /
(50q) G 3J55
Lender
,tioA--C
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
//27 Al r-:
72F, L
H
c
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;
>,,`j�Py
APPLICATION #
Conditions/Comments• On..../ to e�w�.c) .2..,,,..,i", A7
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
ler
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson
I
0 drainage 0 new access/approach; 0 fence;
0 road improvements
Conditions/Comments. /4--71r;47— / C Q.-.
/
•
Utilities:
N. 811 Jefferson
Conditions/ Comments•
Other:
Plan Exam
A(y*Fst/
Fire Prev.
-rLn
1
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