1984, 11-08 Permit App: 00003426 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's Name / (last) / (first)fi (m) Department Only
il/ G/?/ CL- / - `>C �� r I Ass. Comm
2 Project Address(not Mailing Address)or Road NALne Space Zip
• 3 City/Community State Subdivision/Plat Name
/,L,'/4 S 11 ' /{' 7/e `'''5 A 0/2 tre� .---)4 Assessor Pa I No. Lot Block ✓
') o :�7 m E'0
`p� I / * ,t * DEPARTMENT USE ONLY ,t ,t ,t
CX C
J/ 5 Sic Code Zone Act.# Zone Project No.
44 Sc.4
6 Dwell# No.of Buildings Sq.Ft./Acre Depth. Frontage
I A ... I4^' y
7 Set Back-Front 1(L)S-1 (R)S-2 l Rear Census Tract Module No. /` o
. $41
* *
16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
iti(c C /'/ // -S-7-2_ Vz .
Zip/ ( d , City ISta/�/4-i 4 Phone.J `() 9( 6 IF
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 Ch k(YIN) Other(YIN) I SEPA Exempt(Y/N) Date
15 Type Work .Bldg ❑ MH le- Jew ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter 0 Move
14 Describe Work
qE,S VDC NCS
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
1434- 1NVF
64-S 1?2i G Of.
14-34- ct 3
DEPARTMENT APPROVALS - -
This is not a 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 ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
/ructure;
APPLICATION# (1 0®2J
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; 0 Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
414
Engineers: ❑ Commercial; B Ridential; ❑ Flood Plain;
N.811 Jefferson ❑ drainagef�newaccess/approach; 0 fence;
❑ road improvements /
Conditions/Comments: K741
Utilities:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
ci
c
� Project Representative Telephone
as Agencies Performing Special Inspection:
O c 1.
U
cz
~ E 2.
y O
ffl C
V_
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold