1984, 04-09 Permit App: 84A-3101 Garage�K
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)
I
Owner's Name
(last)
Ru �v ` `.1
(first)
-
(m)
Department Use Only
Res. Comm
2
Project Address (not Mailing Address) or Road Name
Space
Zip
3
City/Community
State
Ck
Subdivision/ Plat Name
4
Assessor Pfircal No.
Lot
Block
DEPARTMENT USE ONLY
5
Sic Code
Zone Act. M
Zone
Project
No.
6
Dwell N
No. of Buildings
Sq. Ft./Acre
Depth I
43
Frontage
-7 h )
7
Set Back-Front(L)S-1
j
---1141/1
(R)S-2
Rear
Census Tract
Module No.
Initials
r 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 N1 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
New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14
Describe Work
GC, c-
10
Applicant Name
JJ
Street Address
44
11
Zip _
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
i his is not a Permit
❑
(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 1 Hold 2
Environmental Health
W. 1101 College
Room 200
❑ Commercial; ❑ Residential
F-�w Construction; ❑ Bldg alteration/addition
6d' Additional structure; y-G�sy
APPLICATION # ;F -4/—o a C9 S
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:
'd
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:
Project Representative
Telephone
Agencies Performing Special Inspection:
C
O
1.
ca
E
O
2.
C
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold