1986, 04-29 Permit App: 00010758 SidingBUILDING 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)
/(J TD 4) "tie
Department Use Only
R38.
Comm
2 Project Address (not Mailing Adyess) or RoadN a Space Zip
7/5/ 7 . /� 2�
3 Clty/Community
4`�iI/L
State
Subdivision/ Plat Name
P___.3
4 Assessor No. ���
Lot
Block
,t * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. Y
Zone
Project No. '
/ /
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front t(L)S_l
(R)S-2 I Rear
(knsus Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
/ CoptractoriFirm Name
Street Address
Zip /
City
State i
Phone
Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than 91 abov
PPP
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/ N)
SEPA Exempt (YIN)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
"Add/Alter
❑ Replace
❑ Move
❑ Other
14 Descr Work k'
4-1
10 Applicant
tttNName y—
Street Address /9
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
_—�r j /
>y G
DEPARTMENT APPROVALS
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
r
This is not a Permit
❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
•
Early Start
Release
Release
w/cond 1
Hold
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
2
APPLICATION #
Conditions/Comments•
•
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;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments•
❑
Utilities:
N. 811 Jefferson
Conditions/Comments:
❑
Other:
❑
Plan Exam
Fire Prey.
Conditions/Comments•
1 Information ❑
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
r