1985, 03-12 Permit App: 00004458 Residence •II.Will7
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BUILDING PERMIT APPLICATION WORKSHEET I
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) I Department Use Only
/Q� / / 3f7N F3s. Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
/5, — ,,
3 City/Community State Subdivision/P
./ bg/e /�l' / �� i��% GG///t9X.
4 Assessor Parcel No. Lot 6 I Block
45---13 —/766 / * * * DEPARTMENT USE ONLY * *
5 Sic Code Zone Act.M Zone F,^/ Project No. � r^7
6 Dwell* No.of Buildings I( Sq.Ft./Acre Depth �J1 Frontage
I I l2 " f� t 10 i -r
7 Set Back-Front I(L)S-1 (R)S-2 Rear Census Tract Module No. Initials
30 '
341 Io" , _SON M .
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contr or Firm Name /1<o/C, Street Address �/i/
Zip99, City Stets _ Phone )0g'��°
Contact nO /1��a Li�iR fr 146. ,_ , Phone if different thane
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(YIN) SEPA Exempt(Y/N) Date
15 Type Work Bldg ElMH 1 New ❑ Replace ElOther
17Fire ❑ Demo ❑ Add/Alter E Move
14 Describe o/Xi f //e �, i/%" / j/ >F 6—.--
10 Appla/�r .6:91/1c� / cie Street Address aS QZe
11 Zip City State Phone
( )
*
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
M W = /(98°
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DEPARTMENT APPROVALS
This is nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Track
❑ Early Start Release
Release w/cond 1 Hol 2
Environmental Health ❑ Commercial; ❑ Residential e- . /271",
w.1101 Room 200 College New Construction; ❑ Bldg alteration/addition 8c
❑ Additional
structure; f'
APPLICATION# O G)/..2_3ivh.%
Conditions/Comments: (frAira
❑ 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;l�
N.811 Jefferson ❑ drainage new access/approach; ❑ fence;
❑ road improvements r
Conditions/Comments: `' / ',4 -6 77
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
❑ Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
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Project Representative Telephone
Agencies Performing Special Inspection:
c 1.
Y O
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E 2.
7, O
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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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