1985, 07-17 Permit App: 00006421 Pool1
BUILDING 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)
110M /,�%y, %1)Z /,-6 /, •"
1 Owner's Name
(last)
(first)
(m)
Department Use Only
Ras. Comm
2 Project Address (nW.Mailing Address) or Road Name
3 Gty/Com ugit
Space Zi -
State r Subdivision/ Plat Na e
4 Assessor Parcel No.
�,�•� �,.� �
— /moi �� ,l
Lot
Block
DEPARTMENT USE ONLY
5 Sic Code
Zone Act. M
Zone Project
No.J &�1�
6 Dwell N
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
" 16 Architect Firm Name
Street Address
Zip
cityState
Phone
Contact Person
Phone If different than above
Con actor Firm Name f , }y
Street Address f, Y
J J
Zi J
city.
State
Phone
Cyontact f� n
bl�sO`�wner/Agent
License
99e No.
Phone if different than above
8 (if different than M1 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (YIN)
Other (YIN) SEPA
Exempt (Y/N)
Date
15 Type Work
❑ Bldg
❑ Fire
❑ MH
❑ Demo
New
❑ Add/Alter
❑ Replace
❑ Move
Other
7,771
14 Describe Work
10 A p cant Name
Street Address
11 Zip
State tt Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold
Application Type
This is not a Permit
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
;elease
Environmental Health
W. 1101 College
Room 200
Release /cond 1 Hold 2
❑ Commercial; ❑ Residential
El Construction; EDBldg alteration /addition
❑ Additional structure;
❑
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; ❑ 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:
Project Representative
Telephone
Agencies Performing Special Inspection:
0
1.
E
o`
2
c
3.
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold
l