1984, 07-05 Permit App: 00001031 BarnBUILDING 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)
t COP r C
Department Use Only
Res.
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
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3 Clty/Community
', ; kON e
State
t yr
Subdivision/Plat Name
dol h iorc/ l e Yes -rce A
4 Assessorrcel N .
2[ / ���
~
Lot ,s
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell*
/.
No. of Buildings
2-
Sq. Ft./Acre
I e0 4ferPs
Dept
Frontage
Frontage/
Initials
,7i/cd
7 Set Bade -Front
2_6
(L S-1
!b
(R)S-2
Rear
Census Tract
Module No.
16 Architect Firm Name
Street Address
Zip I
\\\
City
State
Phone
( )
Contact Person [
1
Phone If different than above
( )
Contractor Firm Name
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Street Address
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Zip
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City
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State
1,v `��
Phone
(-� ) V 1— 2 S �
TCAO,'
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 (YIN)
SEPA Exempt (Y/N)
Date
15 Type Work ( Bldg
❑ Fire
❑ MH
❑ Demo
Pr- New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work /� r,%
Cj\C\C�\\ ckr i2 Jy �/ L6 1 Q 7L/
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
1
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1
DEPARTMENT APPROVALS
This is nota 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; �� \
APPLICATION # fl �) CF /V o
❑ Residential
❑ Bldg alteration/addition
Release
Release w/cond 1
Hold 2
10----).-4),\.
Conditions/Comments:
Planning/Zoning:
N. 721 Jefferson
Conditions /Comments
O Commercial;
O Setbacks;
0 Cert. of Exemption;
0 lot w/d;' 0 lot size;
O CU, variance, zone change; shoreline;
0 Frontage;
0 use/zone;
0 fence;
O Other
Engineers: 0 Commercial;
N. 811 Jefferson 0 drainage
O road improvements
Conditions/Comments.
❑ Residential;
O new access/approach;
O Flood Plain;
O fence;
Utilities:
N. 811 Jefferson
Conditions / Comments
Other:
Plan Exam
Fire Prev.
Conditions/Comments
Project Representative
Agencies Performing Special Inspection:
1
Telephone
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold