1986, 05-23 Permit App: 00011160 Resider
BUIL NG 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) Departmen X.1se Only
__L(� C�! / lCt_i Rm. ��
I
Comm
2 Project Address (not Mailing Addy ee) or Road/Name g L Space Zip
�cx6 / �(2 L", t/ , k
3 Clty/CommunityState
j6 «r<<,
r --r %'
Subdiv ion/ Plat Name
rn.i4 i c AVE.
4 r Parcel No.Lot
C i 531-60-
Block
. * . DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 8
Zone A
Project No. % / br,
6 Cowell ft
No. of Buildings
Sq. Ft./Accrreey�
/A
Depth
Frontage
7 Set Bads -Front
(L)S-1
(R)S-2 Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
-7/ll (C�c, �� �-1,.2_—
��
Street Address
7.' : / 7'r��Y k
Zip 3
G/ ci 2.7'
City
City
-2-(1— G�r" -
State
L`1 /�
Phone /f
(;' ,/) z/G/i 4
Contact Person ,y
/ _/✓Se d 212 /%
License No.
%27C. /7 _;,� _ ;214_
Phone If different than above
( )
8 Owner gent (if different an #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
I SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
0 Move
❑ Other
14 Descri Work
10 Applit Named//
Street Address
11 Zip
Cit /
State
Phone 7
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
r C
/ /rc
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; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions/Comments•
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions / Comments
Project Representative
Agencies Performing Special Inspection:
1
Telephone
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
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; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions/Comments•
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions / Comments
Project Representative
Agencies Performing Special Inspection:
1
Telephone
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold