1984, 12-19 Permit App: 00003771 RemodelBUILDING 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�layt)
> <JG j''_i'G
(first)
�91
(m) Department Use Only
Res. Comm
2 Project Address (not Malling Address) or Road Name
i'/ >
Space
Zip
3 Gty/Co^mmu/n)ity
State
Subdivision/ Plat Name
4 Assessor Parcel No,
/ 00�1jS�
Lot
Block
* * + DEPARTMENT USE ONLY +
Act. M
Zone
Project
No. I
No. of Buildings
Sq. FtJ Acre
Depth
Frontage
F5deZone
nt
(L)S-1
(R)S-2
Rear
Cansus Tract
Module No.
Initials
m Name
Street Address
city
7State
Phone
( )
Contact Person
Phone if different than above
Contractor Firm Name _7
Street Address
I S
Zip
city
<
State
Phone
Contact Person .
License No.
Phone if different than above
8 Owner/ Agent (if different than N1 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N)
Other (YIN) SEPA
Exempt (Y/N)
Date
15 Type Work
❑ Bldg
❑ FIre
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
❑ Move
E Other
14 Describe Workf
_'D 5 7
%
Gam" i� ` Gts % -- PIA
10 Applicant Name
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Inform tion
Application Type
(Standard unless
otherwise indicated)
❑ Fast Track
❑ Early Start
❑ Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/ Comments:
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
u
■❑1
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:
�••a^•w•�• VV111111ulwal, u nesioenuai; u hlootl Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/ Comments:
Utilities:
N. 811 Jefferson
Conditions /Comments:
Other:
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
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
Release
Release
w/cond 1
Hold 2
Telephone