1984, 06-11 Permit App: 00000621 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 (last) (first) (m) Department U,e(Only
f
CQ; �� *C/..-5. pSGC j a l e_g 227 4 e_. , itis.
I
Comm
2 Project Address (not Mailing Address) a Road Name Space Zip
IS/g S.. In;1; ss>. � —.
3 City/Community
State
Cu
Subdivision/
!Plat !Name f
4 Assessor Parcel No.
Lot
Bloc
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone✓V'Z
Project No.
iii
6 Dwell#
I
No. of Buildings
i
Sq. Ft./Acre
pth
I ass
Frontage
7 Set Bads -Front
(L S-1 _ i
(R)S-21
Rear
Census Tract Module No.
gals
16 Architect Firm Name
Street Address
Zip
Gty
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name /� /
ie:IL v� /(fss r C �' 2T c�j �hC�.
'State
Street Address
/1ee3Z /4)
Zip Z//
G G t�� •
Phone99 g ^ 7 T
C�ont9ct Person
License NO.
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)
SEPA Exempt (Y/N)
Date
15 Type Work t . Bidg
❑ Fire
❑ MH
❑ Demo
tc New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work "�
SrGi� A F74, -,1;!J �lJ4k l f' l�9 L(� �G� e 0.4). -ti q,
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
/ThLender /
( ;14-../.), 44/' z J C 6 ✓t`C P
Street Address '/
� � 0.` 5 0 h 17 E.
Zip
City
State
Phone
tact Person p '
7h ��./vAar► S 0 M
\
Phone if different t an above
( )
Additional Information
CI{ (L c
*
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Conditions/Comments.
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments*
Engineers: ❑ Commercial;
N.811 Jefferson ❑ drainage
D road improvements
Conditions/Comments.
Residential; ❑ Flood Plain;
new access/approach; D fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
04
U
N
a
c
Y o
co • 715
E
Ty, o
u
• `c
Plan Exam
Fire Prev.
Conditions/Comments.
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Release
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/Comments.
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments*
Engineers: ❑ Commercial;
N.811 Jefferson ❑ drainage
D road improvements
Conditions/Comments.
Residential; ❑ Flood Plain;
new access/approach; D fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
04
U
N
a
c
Y o
co • 715
E
Ty, o
u
• `c
Plan Exam
Fire Prev.
Conditions/Comments.
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
• 00
2 -s
0
00U
Atoc 4, 4
• VI
1) E-
,0/
10
E
44 t /10 #H /Z.v