1985, 04-18 Permit App: 00002965 Relocate ResidenceBUILDING 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)
Ea (--_u— gyp-- .
2 Project Address (not Mailing Address) or Road Name Space
5 . ([ di 2/Zi Fiki(4aA1) GI 12AG
Subdivision/ Plat Name
3 City/Community
b...E.�
State
Department Use Only
Res. Comm
Zip
4 Assessor Parcel No.
04 544- i3O-
5 Sic Code
140 4
6 Dwell
Zone Act. fl
Lot
Block
rJ
* * * DEPARTMENT USE ONLY * * *
Zone 9F (n /
Project No.
2_815/5
No. of Buildings
Sq. Ft./Acre
Depth
12-7
Frontage
1oI
7 Back -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
�utir,.
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 91 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
''Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ Replace
ove
0 Other
14 Describe Work
10 Applicant Name
Street qddress
.9ail�ti
11 Zip
City
State
Phone
( Svr) i2—L, t 7 j
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
Environmental Health
W. 1101 College
Room 200
Conditions/Comments.
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑ Commercial;
Kr New Construction;
❑ Additional structure;
APPLICATION #
❑ Residential
❑ Bldg alteration/addition
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments.
Engineers:
N. 811 Jefferson
Conditions/Comments.
O Commercial;
O drainage
O road improvements
0 Residential;
new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/ Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Protect Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
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
isi 1 %
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments.
Engineers:
N. 811 Jefferson
Conditions/Comments.
O Commercial;
O drainage
O road improvements
0 Residential;
new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/ Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Protect Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
11`12 2. 4- Y >cLJ. CtiLes“.
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