1985, 01-04 Permit App: 00003846 RemodelBUILDING 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) f�(fiirst) (m)
L�d� �i `�' (/Y —
r/
Department Use Only
Fes.
Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
.; 71 I Zf':C. ed
3 City/Community
42.0. 41 �S1f.
State
�ef� 4
Subdivision/PlatName
LOT .3 Flo -e t% !vih77e,(rECa=uJ/om/i`sri
4 Assessor Parcel No. /
4V )
(, 2 146-
Lot
Block
9 [
* * * DEPARTMENT USE ONLY * it*
5 Sic Code
Zone Act. #
Zone
Project No. 5
6 Dwell M
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bads -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
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
❑ Fire
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
D Move
❑ Other
14 Describe Work /
i1%/G 1 /_ N E f yOP� u 1 0 G y�C
�Street
10 Applicant Name
Address
11 Zip
City
State
Phone
( ) 24_97 eo
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
2 0 0 d1 pe'rP 112A, A1,S
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Conditions/Comments
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments-
Utilities:
onditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
ci
co
c
co
c
o
E
ras o
c
Plan Exam
Fire Prev.
Conditions /Comments
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
Release
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/Comments
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments-
Utilities:
onditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
ci
co
c
co
c
o
E
ras o
c
Plan Exam
Fire Prev.
Conditions /Comments
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