1984, 07-25 Permit App: 00001436 Residence BUILDING PERMIT APPLICATION WORKSHEETI
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 Z (last) (first) (m) Department Use Only
CG 1,-...-1 Res. Comm
2 Project Address(not Mailing Add as)or Road Name Space Zip
4.
P'( dJi Q M 11--`�Stat� ~ Subdivision/ Name 5.5')-t,5.5')-t,3 City munity ` j, A
ke,t
4 Asseesorprcel No. Lot .A., Block Red d ,e M 0,-1- & /^ J
-2-•i-5.4
,\l-5 I - 0111 / (I (/ * * . DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone / Project No.
5F IV
6 Dwell ft No.of Buildings Sq.Ft./Acre Depth i r Frontage
1 I -2-e01 o 2-1
7 Set Bads-�t Y I(L)S-1 1 (R)S-2 I Rear Census Tract I Module No. Initials
tt r J 0 N
* 16 Architect Firm Name Street Address
19-A7f,'y 41 I1'c- I /4. / vi., A, j
Zip CityState Phone
q c b S1.L. )ca ( ) 91e-1-5v6
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
( )
Contact Person License No. Phone if different than above
i '. Z44-. P1"NDC. 1 20; Cc) ( )
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(YIN) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
• Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
1\
'1 . F_ (-7 ( S ? k
-77.�
G Det. e7o
PecK - ,1
•
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/coed 1 Hold 2
❑ Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
CI Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; 0 Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; 0 Flood Plain; �g—'..1:51
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
El
Other:
❑ Plan Exam � 1r-1�I
Fire Prev.
Conditions/Comments: �(
a
C
Project Representative Telephone
0. Agencies Performing Special Inspection:
o 1.
E
- E 2
rn o
• c
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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