1984, 08-10 Permit App: 00001710 GarageBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your bullding plans to the Department of Building and Safety)
1 Own Name (last)
Arre(m)
Department Use Only
jvci(first)
Res.
Comm
2 Protect Address (not Mailing Address) cr Road Name Space Zip
/0 6/6 MJ . 9Fa6g
3 CI /Community
State
?(�¢ �/cJ
Subdivision/Pla[Name
OPOa flirt)Ni I BA114-' M paWES
4 Assessor Parcel No.
1' 5-41-,-013¢_
Lot
Block
* t t DEPARTMENT USE ONLY * * *
I 5 Sic Code
Zone Act.*
Zone
Protect No. I )
l t
1 6 Dwell NNo.
i
of Buildings
2,-
Sq. Ft./Acre
Depth
5s I
Frontage
90.1.
+ 7 Set Back -Front I (L)S-1
--5(11-,
(R)S-2
Rear j .
--
Oensus Tract
Module No.
Initials
16
16 Architect Firm Name I Street Address
Zip
City
Stale
Phone
Contact Person
Phone If different than above
1 )
Contractor Firm Name
Street Address
Zip
City
I State
Phone
I )
Contact Person
License No. -
Phone If different than above
( )
8 Owner/Agent (if different than II1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (VIN) 'SEPA Exempt (Y/N)
Date
15 Type Work 0 Bldg
❑ Fire
0 MH
0 Demo
n New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
ray i_.0,0Xa0X-13 -:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( ) ‘I 7.--4 --733<-
Lender
Street Address
Zip -
City
State
Phone
1 )
Contact Person
Phone If different than above
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
D New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Release
Release
w/cond 1
Hold 2
8 -lo -;s l�
Conditions/ Comments.
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;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/ Comments•
0
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage • 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments'
0
Utilities:
N.811 Jefferson
Conditions/ Comments•
Other:
0
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
t: �l'�>
3v