1985, 07-12 Permit App: 00006594 Residence a _ y4 ,
ri
BUILDING 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) Departmen�se Only
1l.!2 4 c� %/ ?.CC:' C /it/c Ras. ✓ Comm
2 Project Address(not Mailing Address) Road Name Space Zip
/7 7 cC 6 l r� SttVe. Subdivision/Plat Name 77- /2—
3 City/Community
4 Assessor Parcel No. Lot 1 Block
25'3/ - *6'7 3 * * * DEPARTMENT USE ONLY * * *
5 Sic Code ' Zone Act.# Zone �� Project No. CP
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ / /Xi, e()
7 Set Back-Front I(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 A ress
l2 /L . . 9e 1,-SS or i,t-'z -Cd •4—X /4/"I/
ZipCity State Phone
f /,._/V d %-'e z"-(//1 /5" ( ) 7_,,-f/-: 'K
igtact Person License No. Phone if different than above
/ c c f c/2f/ 7774 M;in-PK — Y4'49e--- ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) i SEPA Exempt(Y/N) Date
15 Type Work p..--111dg ❑ MH C4�lew E Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work /
/dCZ s1X7f// /E£//&e.Zere l jdx;ze 477 l4,ic(
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
0/ I 11 — -----— .
- r
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/cond 1 Hold 2
41.
Environmental Health n Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; 0 Frontage;
N.721 Jefferson Cl Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage ❑ new access/approach; 0 fence;
❑ road improvements
Conditions/Comments: r
Utilities:
N.811 Jefferson /f ��-
Conditions/Comments: INF
❑ Other: -_-
❑ Plan Exam //ay ,;��
Fire Prev.
Conditions/Comments:
a
c❑
Project Representative Telephone
a Agencies Performing Special Inspection:
c
Y0 1.
as E 2.
y O
C C
V_
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
• 1 - r •- • t
X00 , 0
Nt
o l- , 0 /
,I
f I
V .
00 , oo
/ 7 a -7 so 12ocKy /2_106E_
L-o T 7 / LocK
J