1985, 06-21 Permit App: 00006055 Addition, Remodel l
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's Name (last)� (first (m) Department Uge only
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2 Project Address(not Mailing Address)a Road Name Space Zip
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3 City/Community 1 State>> Subdivision/Plat Name
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4 r Parcel No. LotBlock
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�' 1 5 Sic Code Zone Act.# Zone Project No. .�'
6 Dwell# No.of Buildings Sq.Ft./Acre Depth�� Frontage
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* 16 Architect Firm Name Street AddressI *
Zip City State Phone
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Contact Person Phone if different than above
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Contractor Firm Name Street Address
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Contact Person � �/ Licen a No. `(J'10/ GJ/T 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 Check(Y/N) Other(YIN) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ty.,Add/Alter ❑ Move
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10 Applicant Name / Street Address
11 Zip City State Phone
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* Lender Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
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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.) r
LI Fast Track
Early Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
-1/ .
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional/t lsstructure APPLICATION# 4 th/
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; 0 Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; 0 fence;
O Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
O road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
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Project Representative Telephone
NAgencies Performing Special Inspection:
1.
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H E 2.
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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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