1984, 12-05 Permit App: 00003699 Relocate BldgBUILDING 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
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WO. Comm
2 Project Address (not Mailing Address) or Road Name p Space Zip
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State •
Subdivi ion/Plat Name
cc. �e�' ‘ d�S 1
4 Assessor Parcel No
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Lot
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Block
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,t ,t. DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No. Ct
6 Dwell #
No. of Buildings
i
Sq. Ft./Acre
Depth
(so
Frontage
3
7 Set Bads -Front
(L)S-1
(R)S-2
1 Rear
Census Tract
I Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
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)
SEPA Exempt (YIN)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work `' � F ^ I ` At 0 0N) e iJ 1 2
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10Applicant Name
Street Address ! ,_ FI nk.1 p,
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11 Zip �� o3 —I
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i State
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Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information 4PSI, A`C ff (' !� to
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M 44,04
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
_13Q0171200
Conditions/Comments•
❑ Commercial;
le New Construction;
❑ Additional structure;
APPLICATION #
❑ Residential
❑ Bldg alteration/addition
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Release
Release
w/cond 1
Hold 2
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; D fence;
❑ Other
Conditions/Comments•
Engineers:
N. 811 Jefferson
Conditions/Comments•
❑ Commercial;
❑ drainage
❑ road improvements
❑ Residential;
Rl/ new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
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
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