1985, 04-26 Permit App: 00005191 Residence 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)
1 'O)wner'ss Name (last) (first) (m) Department my IP
/0I LL _. Ro ic.."P J Comm(143s.
2 Project Address(not Mailing Address)or Road Name Space Zip .
n/ 5207 1ller (,1 (1C/2/2
3 Clty/unity State Subdivision/Plat Name_
m o a iv L, _)ti 1-(- E" fi tit 7 trio_ Tv P&-f/
4 Assessor Pdrcel No. , Lot Block
.fit/ ` , `_oL//g * * * DEPARTMENT USE ONLY * * *
5 Sic Code CO �`T Zone Act.# Zone Project No.
/SCP . Jill /
6 Dwell# No.of Buildings Sq.Ft./Acre Depth
I 5 ) I.'-'1 .
7 Set Back-Front 1(L)S-1 (R)S-2 ((Rear Census Tract Module No. Initials
��c Z, . C I fJ0N
* 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#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work Bldg TI MH ,/g.. New ❑ Replace C Other
❑ Fire C Demo ❑ Add/Alter ❑ Move
14 Describe Work
I S1Dc-.-NC 0'/ 6APAU�i
10 Applicant Name Street Address
�,0? Ai 54 sn&C�vT
11 Zip City State Phone
* Cc/21)67 ( ) 917,09 _ 31 ) 0
Lender Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additionallnformatio
M --- '1621n1
12> - J3 - 4 `
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 Hold 2
^'
Environmental Health ❑ Commercial; ❑ Residential
W.1101 College 1 New Construction; ❑ Bldg alteration/additiony�
Room 200 ❑ Additional structure; �p � s-
f3(o (t l "fit ' APPLI ATION# 2' _ /6,52 V/26/6
Conditions/Comments: t % e,. 7i-e-r L' t/----2.1-76.0- 4.,
Lig Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; ,
❑/CU,variance,zone change;shoreline; ❑ fence;
❑ ,v
`.r`.+
Conditions/Comments:
-,•— •-,/....-C.-ICIBim(. /),,_c_ -- -.
'
f*rib
\11
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; ,'\ /A A
. N.811 Jefferson ❑ drainage X" new access/approach; ❑ fence; / i
❑ r d improvements ��/-----47/4/ 4.2 , `
Conditions/Comments: L5/5/ /._, 41. lrve!��u.
6,- ,4_,--7-;,___ _ ....,06/crG ,ffi - - 47 4
El Utilities:
N.811 Jefferson
Conditions/Comments:
El
Other:
171 Plan Exam r;,vY-ccS
Fire Prey.
fica
Conditions/Comments:
C,
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' ❑ Project Representative Telephone
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a. Agencies Performing Special Inspection:
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it E 2.
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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