1985, 05-15 Permit App: 00005419 ResidenceBUILDING 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) - t(first) (m)
)i,✓gTT 5 U� /5ref I�
*
DspartmentyseOnly
R3S. Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
G. 76.1 17 c �- 7-1-k K I Q I(,)— Lkivsi
-
3 City/Community
State
W/!5 h
Subdivision/ Plat Name
iz---C= Ii'ivIZil 1
4 Assessor Parcel No.
ot.>`i -3IcG. S(trjz (-ri
Lot
Block
,t * ,t DEPARTMENT USE ONLY ,t* ,t
5 Sic Code
Zone Act. #
Zone
c_
Project No.
G� r��j
6 Dwell #No.
of Buildings
1
Sq. Ft./Acre
Depth ,
eC
Frontage
SIU
7 Set Back -Front
_
(L S-1
(R)S-2I
10
Rear
-
Census Tract
Module No.
Initials
,_1v iY1.
16 Architect Firm Name
z NAYS
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
tTl�C K I/ f/✓i; TTS
Street Address
E 77/ 7 se /?W e l w, Y
Zip
% 9 02.i x
City
5?O/r'IiNl.
I State
WMsh.
Phone
(,)"c7 1 924- ? /
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) 1 SEPA Exempt (YIN)
Date
15 Type Work !,_ Bldg
❑ Fire
❑ MH
❑ Demo
New
E Add/Alter
❑ Replace
❑ Move
E Other
14 Describe Work
10 Applicant Name
Z-�ek 1/ )4//-17'7'5
Street Address
47 79/7 .. ifILie R,,,wif/
11 Zip
`19..z/a_
City
s/'0/-/4ni E
State
1/6r156
Phone
(.5"c7 ) %.Z4- 7h/d p
Lender
/I/o/✓5
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Additional Information
/Q20 =I F
1Q26 = ui'
52g = (A k
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
fliEf
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
APPLICATION #
❑ Residential
Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
1
Condltions/Comments•
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments:
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
X Other Pal N C, p P' f:41 t 0 f= -hoc'
p j 3• i of (Fcet- a t -Z frt, of -
130'
f -130 Cr)
Engineers:
N. 811 Jefferson
Conditions /Comments.
❑ Commercial; ❑ Residential;
❑ drainage Id new access/approach;
❑ road improvements 7.
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
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
•
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