1984, 12-10 Permit App: 00001857 ResidenceBUILDING PERMIT -"APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERST
(Please return this original and your building plans,to the Department of Building and Safety)
1 Owner's Name (last) (first) (m)
I Department Use Only
A LJ L D )C D s �-
f AS. Comm
2 ProJect Address (not Mailing Address Name Space Zip
3 City/Community
ttA »t E
State Subdivision/Plat Name
1iv/4-5-)_
4 Assessor Parcel No.
/ 9543 — 'C: 0 7 /
Lot
Block
* * * DEPARTMENT USE ONLY * * *
/ 5 Sic Code
Zone Act. a
Zone %�ri
Project No. 1867
6 Dwell a
1
No. of Buildings
/
Sq. Ft./Acre
Depth
/`/Q 5
Frontage
/6)0
7 Set Back -Front
72—
(L S-1
(R)S-2
Rear
2C
�
Census Tract
Module No.
Initials
fpy i
16 Architect Firm Name
74..?ffv z_ .L,ikLb D
Street Address
/5-0 '7 o l C, NI E-Csi7
7. 9 2 0 (,,
City
-5 ? (-) --1‘ lq L
State
\A/ . n H
Phone
( ) 9)Z-4 - 6. 5; / S""
Contact Person
., A t,,L /4 ".' 1\ '--c..I F
Phone if different than above
( )
Contractor Firm Name
�� /4 /- v JC
Street Address
2_ D G z � -c) L.) 1 11 F / A
Zip
99z i
City
�1v—J14-,.)
State
( /\/
Phone
( ) Z. 4> — Z-. -..-it,
Contact Person
el N. -C-- ,4. / jea�
-
License No.
Phone if different than above
( )
8 Owner/Agent (if different than #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 to
❑
Bldg
Fire
❑ MH
❑ Demo
l�ew
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
re sic/C
l e e_% l ICi/'C��.I �
7 h ec/
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender AStreet
IN -7 f
Address
Zip
City
State
Phone
( )
Contact Person
'
I
Phone if different than above
( )
Additional Information - . ` 3 �t ,.
-7 tAil-
l1 1,1 1; ';1
�, �j
y,' , yam/\
� ,_. 1Y
*
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
Conditions/Comments.
❑ Commercial;
❑ New Construction;
❑ Additional structure;
APPLICATION #
❑ Residential
❑ Bldg alteration/addition
..
•
79/2-z-er-v-edoy4,74--,74..d.,
Planning/Zoning: ❑ Commercial;
N. 721 Jefferson ❑ Setbacks;
❑ Cert. of Exemption;
❑ lot w/d; ❑ lot size;
❑ Frontage;
❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments.
5x
5g
4
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood 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•
Reo
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
79/2-z-er-v-edoy4,74--,74..d.,
Planning/Zoning: ❑ Commercial;
N. 721 Jefferson ❑ Setbacks;
❑ Cert. of Exemption;
❑ lot w/d; ❑ lot size;
❑ Frontage;
❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments.
5x
5g
4
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood 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•
Reo
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
fr
4
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