1985, 09-06 Permit App: 00007284 SidingBUILDING 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) f(first) (m)
Department UsesMly
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avit
R Comm
2 Protect Address (not ailing Address) a Road Name
$ a1ao /4
Space , ' f
zip p�
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3 Gty/Community
. l-dA4.,
State /n
/414
Subdivision/Plat Name
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4 Assessor No.
taB5-Z/1( " _t`VS
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Lot
`3
7
Bieck
,li
- ..
• + , DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act. #
Zone
5rrz
Project No.
`120
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front I (L
'Rear (R)S-2 `Rear
Census Tract
Module No.
Initials
_1
s 16 Architect Firm Name 1 Street Address
Zlp
City
State
Phone
( 1
Contact Person
Phone if different than above
Contractor Fivn Name
Street
Address
ZIP
Gty
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Stateone
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ersono
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.
License No.Phone
iii/%YRc
3ytini
If different than above
95IWC
8 Owner/Agent (if
afferent than #1 above)
Busl
ess Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
1 SEPA Exempt
(Y/N)
Date
15 Type Work 0 Bldg
0 Fire
❑ MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
x1 Othe��� , n
.!/ t ,
14 Describe Work /J
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10 Applicant Name o
4�
Street
Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone If different than above
( )
Additional Information
IA pp
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DEPARTMENT APPROVALS
o
•
•
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
1 nis is nota rermli :--- - •• -
(Indicated approvals required In either "release" or "release with conditions"
• space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
•
Environmental Health 0 Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alterationladditlon
•
Room 200 0 Additional structure; '
-
APPLICATION # - -
-
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:
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage ❑ 0 fence;
new access/approach;
❑ road improvements
Conditions/Comments-
•
Utilities:
N.811 Jefferson
Conditions/Comments.
•
Other:
Plan Exam
Fire Prev.
Conditions /Comments
' Information ❑
Project Representative Telephone
Agencies Performing Special Inspection:
1
2 '
3
1 Indicate above or attach condltlons relative to final as built approval
2 - Indicate above or attach reasons for hold