1985, 03-12 Permit App: 00004422 MH*
*
M
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)
Department Use Only
T
1- .S co D H 4 /7 / -.L%.)
Fbe. Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
/ 2W.S L r 8e' ? 7 ,1 arm 99 2 i
3 City/Community
S�v h 4.4._...--..s.,./
State
4,1_
Subdivision/ Plat Name
p O i✓ t.✓o-7 _ 4i S 7-
4 Assessor Parcel No.
d G S,,.S' Y a., d 9 / /
Lot
//P
Block
-y
/
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #Zone
,2e- I0
PM I-1
Project No.
'Al 2
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Dept
Frontage
7 Set Back -Front
(L 2S-10
(R)S-2
� Rear
Census Tract
Module No.
Initials
95�
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( 1
Contractor Firm Name
Street Address
Zip
City I
State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( ) (12-8 , /15Q
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
13-141-I
0 Demo
few
0 Add/Alter
❑ Replace
0 Move
0 Other
14 Describe ork / 2
fJ Cceo^/, 5iny,/& Lu!C/e- w/C!ou6/e. c.clyd&, ,,,g,,, g,„,,,10
Appl' nt Name /
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional I nformat ion
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
i
1
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;
APPLICATION #
O Residential
❑ Bldg alteration/addition
Release
Release w/cond 1
Hold 2
Conditions/Comments•
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑ use/zone;
O CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments•
Engineers:
N. 811 Jefferson ❑ Commercial; 0 Residential; 0 Flood Plain; I
O drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
Project Representative Telephone
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
• /if=le,_5E Li'71/
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71
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