1985, 06-06 Permit App: 00005773 Reroof, AdditionBUILDING 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)
10
1 Owner's Name (last) (first) (m) Department Use Only
gF-/I if 6- ! N I* R3s. Comm
I
2 Project Address (not Mailing Address) a Road Name Space Zip
y 0kA0// ./1Q7-3'�� o
3 ylCommunity
State
SubdivisionlPlat Name
4 Assessor Parcel No.
/ g:1t 2 - 01/ 3
Lot
/ 3
Block
'
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone 146 S148
Project No.
6 Dwell #
I
No. of Buildings
I
Sq. Ft./Acre
Depth
(f31
Frontage
6(-`1(1
7 Set Back -Front
55 I a o(4)-
II (L S-1 i
1 G
(R)S-2
__
I Rear
Census Tract
Module No.
Initials
JrOYi1 .
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
( )24— CM73
12 Review Required
Plan Check (Y/N)
Other (Y/N) I SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
❑ Move
,- Other
14 Describe Work
12- — I7-6(�F ( NO PP®?T1 O1\
10 Applicant Name
Street Address
11 Zip
City
State
- Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
i
Additional Information
DEPARTMENT APPROVALS
❑
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release w/cond 1
Hold 2
❑
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ 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 ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments•
•
Utilities:
N. 811 Jefferson
Conditions/Comments•
•
Other:
•
Plan Exam
Fire Prev.
Conditions/ Comments •
IInformation ❑I
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
/43.3
A
ADDRESS: . 02-'11 -(1'Q
General -
'"Ownership
❑ Applicant
❑ Contractor
❑ Architect
OAddress -
Legal Description
Nyll(Parcel Number
Hing
Site Plan
❑ Plat Map
❑ Permit Description
❑ Plans
❑ Completeness
PROJECT it:
Health
Increased Lot Coverage?
Addition Bedrooms/
Fixtures?
Change of Use?
New Septic?
Plannin
Unplatted Property?
Lot Depth: Width > 3:1?
(Less than 10 acres)
Lot Depth: Width > 4:1?
(10 acres plus)
Lot Size Less than Minimum?
Yes
No N/A
L
Segregation of Platted /
Property ?
Setbacks Less than Required?
Frontage less than Required?
Not a Permitted Use In Zone?
Rezone, Conditional Use,
Variance Involved or Required?
❑ Square Footage Commercial Use or Home
Occupation?
,IErccupancy Group & Type More than One Residence?
❑Departmental Releases Adjacent to a Required
and Conditions - Shoreline?
REVIEWED BY:.
En
1neeri
n
New Access/Approach?
z
Private or Unmaintalned /
County -Road?
Se•a
Underground Tank Over
10,000 Gallons
Commercial Building Over
12,000 Square Feet?
Over 20 Dwelling Units?
Over 40 Parking Spaces?
Agricultural Building Over
20,000 Square Feet?
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical
Use Activity?
DATE: 6164.E