1984, 06-04 Permit App: 00000495 Pool2 Z 1UILDING 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) Department Use Only
Pei( ToeI Fes.
I
`J
Comm
2 Project Address (not Mailing Address) a Road Name Space Zip
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3 tyty/Commun1ittyy
j.� O ti. A -N
State
/131ock
Subdivision/Plat Name f� Ada
f t vie l i, 4 o Ire i da . /ice ;
4 q�(r Parcel 4 i — 1 3 0 i
Lot
y
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act.#
Zone��
Project No. {15
6 Dwell N
No. of Buildings
Sq. Ft./Acre
Depth[
56
Frontage
7 Set Back -Front
)(1�i -
(L)S-1
(R)S-2 j Rear
I
1 !Rear
Census Tract
Census
Module No.
Initials
J0 Ni 0,71
16 Architect Firm Name
I Street Address
Zip
Gty
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name ,1 (
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Street Address
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Qp
`i
City
t 4've
State
cx./A-
Phone
C 37
) 32 7-5 2 2
[
Contact Person
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l
License No.
Phone if different than above
( )
8 Owner/Agent (if different than 81 above)
Business
Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check (Y/N)
Other (YIN) I SEPA Exempt (YIN)
Date
15 Type Work ❑
❑
Bldg
Fire
❑ MH
❑ Demo
❑ New
0 Add/Alter
❑ Replace
❑ Move
❑ Other
Describe Work
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10 Applicant
Street s
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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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;
APPLICATION #
❑ Residential
E Bldg alteration/addition
Conditions/Comments: �,/ 6ufi 6,.r,te "PLfreefil
Release
Release
w/cond 1
Hold 2
n
5 -3/-8'f
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; E lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments.
Engineers: ❑ Commercial; ❑ Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; D fence;
O road improvements
Conditions/ Comments:
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
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