1986, 06-02 Permit App: 00011344 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)
Department ly
Rea. Comm
2
Project Address (not Walling Address) Road Name
//61-1 17
Space
Zip
3
4
City/ Community
Assessor Pfircel No.
195
/ _
lee,&
State Subdivition�Plat Name
Lot Block
/_ * * * DEPARTMENT USE ONLY
5
Sic Code Zone Act. M
010001
Zone
S
Project No. / / L/-
��
6
Dwell
No. of Buildings
Sq. Ft./iAcre
s�.q,+�
1�
Depth
Frontage
7
Set Back -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
C ,
StreetAddress
1C
Zip
City
State
Phone
Contact Pprpon
License No.
Phone If different than above
8
Owner/ Agent (if diff t than N1 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
lz
❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
❑ Move
❑ Other
14
Desc :JWork
_
10
Applicant Name
Street Address
`
11 Zip Q117
� / off,
City
GS/�L�ll
State/ p 1
W/c/
Phone
( —�4?
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
( 1
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
�—
I nis is not a vermit
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 1Hold 2
❑
Environmental Health
W. 1101 College
❑ Commercial; ❑ Residentiali
❑ New Construction; ❑ Bldg alteration/addition
Room 200
❑ Additional structure;
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 1:1new access/ approach; 11fence;
11road improvements
Conditions /Comments:
❑
utilities:
N. 811 Jefferson
Conditions/ Comments:
❑
Other:
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
C
O
1.
E
2
o`
c
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold