1985, 01-30 Permit App: 00004053 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)
1 Owner's Name 46e4, -KreF) (m) Department Use Only
3/4✓E/e , Fbs. Comm
I
2 Project Address (not Mailing Address) or. Road Name Space Zip
S 3902— ,i/.2 -Z , ”0476:.
3 City/Community
S�'c�:4-
State
4
Subdivision/Plat Name
IC,7-/.S CXfr 9 M' /4c/we .
4 Assessor Parcel No.
Lot
Block
14/
* * * DEPARTMENT USE ONLY
5 Sic Code
Zone Act. #
Zone
Project No. ()5
6 Dwell #
I
No. of Buildings
i
Sq. Ft./Acre
Depth
IzS
Frontage
93
7 Set Back -Front 1 I ff (L S-1
3o l
(R)S-2 !Rear
Zg' 4 ,
Census Tract
I Module No.
Initials n^
..J'V1 Y Y 1
16 Arch tect Firm Name
bk'A-T % 711/41 C -e .4 t i C-5 n✓'
Street Address
N, c?"l�•o4-. Di v / sfcrnf
Zip
9'9zCi.
City
SPc-vC.,_
State
'j'v,.4-
Phone
(Svt) r27-C;z.c2
Contact Person
LT -&---Fr --i4'l dv L-
Phone if different than above
( )
Contractor Firm Name
life 8/4 (v-Ny. ai 1c .
Street
Address
7 9,/7 4V6 -1.f s rii
Zip
9 90/ co
city/v,
�'ee s
State
f ,4.
Phone Sod) `/� �_����
,'contact Person
/3eLiCe `WA -;_r-5
License No.
.eC,el4 e. --1-- /7 Yc7g
Phone if different than above
(s??") Z7-2.2 /
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)
SEPA Exempt (Y/N)
Date
15 Type Work ;PC Bldg
❑ Fire
E MH
❑ Demo
New
❑ Add/Alter
E Replace
❑ Move
❑ Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
G�r3Si/:Nc>r v/'r%r Z' -5/4
Street Ad ess
G. t '�� 7Y2—
Zip
c7i(r 3
Cit
_ —
State
rev 1.
Phone
( 5-6)9 y .1-.5---- 729/
Contact Person
L y ni n/
Phone if different than above
( )
Additional information
'tn' - 13 V
6 Pel- ; 491
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; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/Comments• .3•',—ice v
•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; ❑ 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.
/
11
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
❑ road improvements %
Conditions/Comments• r V//11 O/S
Utilities:
N.811 Jefferson
Conditions/ Comments*
--
•
Other:
•
Plan Examrem
Fire Prev.
Conditions/Comments.
_.......„
r4 i
r oti__
Project Representative Telephone
Agencies Performing Special Inspection:
1
` Informati
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
N
w'
5l
GAR A ve
S. 34oL p1//_/551.)
Lc); / 1.5'e c 4 /H,L,corng .3/Y AlaN
E/V(::,Nee,' sehtte id 3o
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