1984, 07-31 Permit App: 00001701 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) Depart Only
(m) /7Q%
'
� Comm
�?� �\<� �\���) .�U�\\ � `V �� I
2 Project Address (not Mailing Address) or Road Name Space Zip
3 City/Community
G' R 4 K\ �
State
W c
S bdivlsion/Plat Name
\ s_..--, W S`.\'‘\\..\—\\<.,\).\
40Assessor Parcel r09
Lot
Block*
* * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act.*
Zone_
Project No.
6 Dwell4
No. of Buildings
Sq. Ft./AcreDepth
I
Frontage )
7 Set Back -Front II(L)S-1
'h` I
(R)S-2
Z�j
Rear
Census Tract
Module No.
Initials
,J0N (Y1.
16 Architect Firm Name
�c2 -N\\G -0��\ v\
Street Address
=�C6�T3\ �, .oV.
Zip
Contact Person
`
Phone If different than above
Contractor Firm Name
'b \„N.4 Co\
S'�V" \--.1--"...N• 6vN
Street
Address
0\._.._\� - 'Q v\-_-"--
Zip
p l
\`a- kcj
City
� S 0.2*._ �
State
V 0.-(g
Phone
y )
\ Ck.....10 `S k)
\ Contact Person
SIJ 0—� C-�}� ._ *.
Licenseic/No.
4 V %� Z fg7
Phone if different than above
( )
8 Owner/Adept (if different than #1 above)'
`
N�
G t
_- /r T /d�
Business
Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check (Y/N)
Other (Y/N)
SEPA
J
Exempt
(Y/N)
Date
15 Type Work IBS
0
Bldg
Fire
0 MH
0 Demo
1' New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work _ �_
C
-stt3=c_ -<"'"'"\<,
,....1.- c-----',_
v.....\ ";k\J•&... IQ_
10 Applicant Name
�r
.'7-c--\
\\
Street
Address
11 QZipp SCity
lb
State` _ `
Phone r�
\Zk-
er
K_C'— )S \ C c�� k
Street Adds`..; i o1`. 1
Zip
City
Statel - `
Phone r
Contact Person
Phone if different than above
( )
Additional Information
`
r
r zLAE gJ
.1LB 31 i99
6A42-
EflE1VE
016 Dec
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
O Bldg alteration/addition
Release
Release w/cond 1
Hold 2
grin, riff%
FA' eq
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage new access/approach;
O road improvements
Conditions/Comments.
0 Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/ Comments•
Other:
c
IEJ
Information
Plan Exam
Fire Prev.
Conditions/Comments:
apAtc.-
"F(Acki,3
Project 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
C.)0(.1)
\
t 1
71 ,
v (1,
Vs:
AV( eOtlAttliCtiOn
E. 9211 gunt
.7S o CM. 99206
Th
1-7 °It
v).01
-7
4
Aloft eonsttuction
8. 9211 gurti
Spactizz, Wa. 99206
•