1984, 05-21 Permit App: 00000210 ResidenceG
BUILDING PERMIT APPLICATION WORKSHEET
dIPPLEASE 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)
a
(last)
(first) (m) Department Use Only
Rss.
1 Owner's Name y
":"1-1,t-1 ;ad
Space
2 Project dress (not Mailing Address) Road Name sit
D ��
State Subdivision/Plat Name
11)1 I PI t a) -ate Pri)P
1 Comm
3 City/Community
4Assessor Parcel No. Po`V1 WN �F
5‘l UO1
5 Sic Code
Zone Act. S
Lot
Zip
4
Block
4
No. of Buildinfls
Zone s�;h
Sq. Ft./Acre
* * * DEPARTMENT USE ONLY * * *
Project No. -7 D•
6 Dwell# I
Rear Census Tract I Module No.
7 Set Ba � .� (L) ) I(R)S -2
--7 l I (Ai
I Depth
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16 Architect Firm Name
La
Zip I City
Contact Person
*
Contractor Firm Name
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Zip
99c O /
State
IStreet Address
Phone
( )
Phone If different than above
Frontage
1910
Initials ,J 0 tJ ry
I'
IStreet Address
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City
I State
Phone
Contact Person
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8 Owner/Agent (if different than #1 above)
1 License No.
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Phone If different than above
( )
Business Address
9 Zip I City I State I Phone
( )
12 Review Required
15 Type Work
1Plan Check (YIN) I Other (YIN) I SEPA Exempt (Y/N) I Date
I Bldg
❑ Fire
14 Describe Work
10 Applicant Name
I ❑ MH
Cl Demo
5i d��1C�
11 Zip
Lender
le' New
❑ Add/Alter
0 Replace
❑ Move
❑ Other
IStreet Address
1 City State 1 Phone
( )
IStreet Address
Zip
Contact Person
1
City I State
Additional Information {,
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14o
Phone
Phone if different than above
( ) „
9-76 Q
*
Abk
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
Environmental Health
W. 1101 College
Room 200
Conditions/Comments:
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑ Commercial;
❑ New Construction;
O Additional structure;
❑ Residential
O Bldg alteration/addition
APPLICATION #
Release
w/cond 1
Hold 2
Planning/Zoning:
N. 721 Jefferson
Conditions /Comments:
0 Commercial; ❑ Cert. of Exemption; 0 Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Engineers:
N. 811 Jefferson
Conditions /Comments:
O Commercial;
O drainage
O road improvements
0 Residential; 0 Flood Plainy/�_ ,jI
[�new access/approach; 0 fence; 7
Utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prev.
Conditions/Comments:
Project Representative
Agencies Performing Special Inspection:
1.
2.
3.
Telephone
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold