1985, 06-18 Permit App: 00005961 Replace Flat Roofn
.rJ 71
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) (m)
Department Use Only
TO ?r In V (, 4
T ( L(first)a-
Ras. Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
S 1 1 11 pi U e 1-- o --a 9 7 a a
3 City/Community
0af90V-Ts) ti" (T
State
-wa s
Subdly)sion/Plat Name
1-rl.G{1 M37Y-z,
4 Assessor Parcel No.
_-7 -4 (/ — 1Iif4
/
Lot
Block
+ ♦ t DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 0
Zone V
_„ /
�i�f/IS/q.
Project No.
6 Dwell p
No. of Buildings
Ft./Acre
Depth
Frontage
7 Set Back -Front I (L)S-1
(R)S-2 I Rear
Census Tract
Module No.
Initials .
18 Architect Firm Name I Street Address
Zip
O d 11.1 .o_..-
City
State
Phone
( )
Contact Person
Phone if different than above
Contractor Firm Name
/5a -e__
Street Address
Zip
City
State
Phone
Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than P1 above)
Busi ess Address
9 Zip
City
State
Phone
12 Review Required
Pia Check (Y/N)
Other (YIN)
I SEPA Exempt (YIN)
Date
-"' 15 Type Work 0 . Bldg
0 Fire
0 MH
0 Demo
0 New
X Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
Pvt 0-a.6(c hoof o-, &ia7` J. aoi
1 Applicant Name
I M o b0?
Street Address �"
3 a o 4- i- � e-4 �vfj kiy r 0'-
11 Zip
9901 F
City/
�c5e,f7 G-ak-
State
wt..-__
Phone
(aS'5--773
Lender
Street Address
Zip
City
State
Phone +
( 1
Contact Person
Phone if different than above
( 1
Additional Information
t
f
t0
0
a
N
U
F
to
N
LL
••
DEPARTMENT APPROVALS
•
•
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
I rias Is nor a rermlr
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
APPLICATION #
Conditions/Comments'
0
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;
0 Other
Conditions/Comments'
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 0 fence;
new access/approach;
❑ road Improvements
Conditions/Comments'
•
Utilities:
N. 811 Jefferson
Conditions/ Comments•
•
Other:
El
Plan Exam
Fire Prev.
Conditions/Comments'
IInformation a
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