1984, 04-06 Permit App: 84A-3034 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) Use Only
!Department
(Jo. S p A5_s-0,;41,••s, Z Y1 e • %S.
Comm
2 Prof Address (not Mailing Address) a Road Name Space Zip
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3 City/Community
State
Subdivision/Plat Name e0t- ,->Gr . 'S`. t- I 0
!
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&0,3.p
c� ✓ a " Thi► �>
4 Assessor Parcel No.
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 8
Zone
Project No.
6 Dwell0
t
No. of Buildings
)
Sq. Ft./Acre
\
Depth
\\6
Frontage
\`= 0
7 Set Bads -Front
(L S-1
(R)S-2 1
Rear�� ,
Census Tract
Module No.
Initials
16chltect Firm Name /
ijr
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Street Address L
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1Zip
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State
Ofre
Phone ) /
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Contact Person
Phone if different than above
( )
Contractor Firm Name
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Street Adgcpas� �
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Zip
P7' Z7/
City
S�cSk�>P .
State
CP>c.._
Phone /
(Safes') 12 c` - ‘f,C�
Contact Person
// `r -7r f 2-;
License No.
Phone If different than above
( )
8 Owner/Agent (If different than 81 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other
(YIN)
SEPA Exempt (YIN)
Date
15 Type Work @' Bldg
❑ Fire
❑ MH
❑ Demo
New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
P
10 Applicant Name
l \,f ` 'r I ^ T 4-.1
Street Address
---7-.4:4
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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
❑ Bldg alteration/addition
WA/tvitt
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;
N. 811 Jefferson ❑ drainage
❑ road improvements
Conditions/Comments•
sidential;
lifelew 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
Release
Release
w/cond 1
Hold 2
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;
N. 811 Jefferson ❑ drainage
❑ road improvements
Conditions/Comments•
sidential;
lifelew 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
1
4
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