1986, 04-29 Permit App: 00010760 Addition (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your buiIding,,hlans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE /��� --
Project Number
Owner's Name LAST FIRST MI
0/1.--- I-r EEO E
Project Address(Street Name&Number) t Zip
/9a0 SO tom, eil,"rrta) r NOL)e/7t 4Ljr WA 9tL 3 7
~Applicant Address/
(/ee4.7 1 eeitO,c) tiii ceeoe6=S (' ` PO, ,d 0A (is--67
City State Zip Phone
� a oa (s?),) ?a-17 pa
Business Phone n e' 1' ^
Contractor/Agent Address
City State Zip Phone
Contact License Number(Required) Business Phone
I EO,tt 4• ttk' r1#e-77 - �C X26,4-r _
Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State 1 Zip Phone
I ( )
Describe Work Res„.....„.....„- Comm.
v CCK Pore Ttc$ (/D)( L)
Subdivision/Plat Name/Short Plat Number
Pi oG-E 1-(o T Esr4 S 106 2
Assessor Parcel Number Lot Block Plat Number
2,55* _ e)3/e) it 3
Pertinent File Numbers Zone Comp.Plan Census Tract
SFA'
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) 1 Depth Frontage
I I // 6 i9z1-
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
/ 5
z
O
F
Q
2
ccO
IL
Z_
0
_Z
0
—J
5
al Number of Bedrooms
Building Techs cian Date Group Type
I -3 v/J
DEPARTMENTAL REVIEW
•
Cond.Approval Approved Hold
Environmental Health Application#
❑ W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
0 N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
❑ Fast Track/Special Inspection information
Project Representative Phone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application is true and correct.
•
lh a
Signature • �% ��. �*. � �i.Z.r Date .27- F6.