1984, 11-07 Permit App: 00003314 Residence 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'sm
N e (last) �( (first) (m) I Department Only
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2 Project Address(not Mailing Address)or Road Name Space Zip
3 City/Community
State �L Subdivision/Plat Name
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4 Assessor Parcel No. Lot Block
14,59-2-
CA,.) ik'fr141 2.- * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage,
7 Set Back-Front I(L)S-1 (R)S-2 l Rear Census Tract Module No. l I Is ^
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* 16 Architect Firm Name I Street Address *
Zip City State ll Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
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Zip City I State Phone
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Contact Person License No. Phone if different than above
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8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan C eck(YIN) Other(YIN) SEPA Exempt(YIN) Date
15 Type Work fr Bldg ❑ MH U1 New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
S t 0ENCX
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
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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
Environmental Health ❑ ommercial; /Residential `r6��k!?�
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; sidential; ❑ Flood Plain;
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N.811 Jefferson ❑ drainage new access/approach; El fence;
CI road
road improvements
Conditions/Comments: ! 41i' - ZS
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
El
Other:
VPlan Exam
Fire Prey.
Conditions/Comments:
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— Project Representative Telephone
a Agencies Performing Special Inspection:
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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CONTRACTOR: I f t
HT.MALAYA HOMES, INC. I I
PROPERTY ADDRESS:
1021 N. Skipworth
LEGAL DESCRTPTTON:
S2 of L1, 132, VALLEY MEADO`:
STJBDIVTSION I f
PARCEL NO. : 15542-0921
SCALE: 1" 20' _� l
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