1984, 07-16 Permit App: 00001183 GarageBUILDING 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)
4/'e _J o4 h
(m)
/ `
Department Use Only
fbs. Comm
2
Project Address (net Mailing Address) or Road Name Space
C- 7 7o PSova ��
Zip
9 Z i 2
3
City/Community
O 4
State ^
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Subdivision/Plat Name /� ,' /�
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4
Assessor Parcel No.
& 5 q 3
Lot
Block
DEPARTMENT USE ONLY
5
Sic Code
Zone Act. M
Zone Project
No.
6
Dwell ff
No. of Buildings
Sq. Ft. IAcre
Depth
Fronta e j
7
Set Bads -Front (L)S-1 i
( I)S-2 Rear
03nsus Tract
Module No.
Initials
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 M1 above)
Business Address
9
Zip
City
State
Phone
12
Review Required
Plan Check (YIN)
Other (YIN) SEPA
Exempt (Y/N)
Date
15
Type Work ;�b Bldg
❑ Fire
❑ MH
❑ Demo
A New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14
Describe Work
z
10
Applicant Name // QS
o 4
Street Address
11
Zip
City
State
Phone
Lender A
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
15
DEPARTMENT APPROVALS
❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
This is not a Permit
(indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
Release
Release w/cond 1 Hold 2
Er
Environmental Health
W. 1101 College
Room 200
❑ Commercial; ❑ Residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional tructure;
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:
Project Representative
Telephone
Agencies Performing Special Inspection:
0
1.
E
0
2
c
3.
Indicate above or attach conditions relative to final as built approval
Indicate above or attach reasons for hold
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