1984, 11-05 Permit App: 00003193 Garage, AdditoinBUILDING 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)
(first) (m) f Department Use Only
1 Owner's Name (last) f
Res. � Comm
�j.Oj dytc S'.
Space Zip
2 Project Address (not Mailing Address) or Road Name
Zc
0.5.-3/ SCr
3 City/Community
COlst�l
I State
Ale
aa
I Subdivision/Plat Ne
j k LV
S L\ J . � 'T O
.s
4 /Assessor Parcel
4
�No' (5 O
Lot
I Block
* * * DEPARTMENT USE ONLY
5 Sic Code
I
Zone Act. #
Zone
Project No. /�t �,i /Z
"
6 Dwell #
1
No. of Buildings
1
Sq. Ft./Acre
I Depth
t
Frontage
a
7 Set Back -Front (L)S-1
3�I 3 1
(R)S 2
-
Rear
Census Tract
Module00
Initials
*
16 Architect Firm Name
Street Address
Zip
City I
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm e
h
J / �
/ (
C "c k fir 2
Street
/-75-"ZTCt
Address /1
rLc1c./,/
�J Ai
Y7�7
City
State
Phone
( ) 92 P- 89o7
Contact Person
Ja L Pszoktel
License No.
✓cA 26 c iEs/c Z)
Phone If different than above
( ) __._
t
8 Owner/Agent (if different than #1 above)
Business Address
SG kW L.
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other (YIN)
SEPA Exempt (Y/N)
Date
15 Type Work
}i7., Bldg
D MH
❑ New
❑ Replace
0 Other
0 Fire
0 Demo
0 Add/Alter
0 Move
14 Describe Workt
6A/it _ kPi i n od �s .� --2- )( 21- OU 5 Q) .s (11,,
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person /CJ 2W
Phone if different than above
( )
Additional Information
f = ' tiI , '
�i
{,q
1 y" ja
6
Y 1 V
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
❑ Commercial;
❑ New Construction;
EC Additional structure;
APPLICATION # 30/0I76
❑ Residential
❑ Bldg alteration/addition
Release
Release w/cond 1
Hold 2
ll S P¢
Conditions/Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size;
❑ CU, variance, zone change; shoreline; ❑
❑ Other
Conditions/Comments•
❑ Frontage;
❑ use/zone;
fence;
Engineers: ❑ Commercial;
N. 811 Jefferson 0 drainage
O road improvements
Conditions/Comments:
❑ Residential;
❑ 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
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
7