1984, 08-10 Permit App: 00001715 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/ 7�/� (last) /(first) (m)
c, / //�7 ��/!,7/t� /
Department Use Only /7�'
WO.
Comm
2 Proj�ess (not Mailing Address) ar RoadNam Space Zip
5, /o d 5/ 5-766rrr-le ST 9fic53 7
3 Clty/Co.mrnittyy,
V e -I acr(e_
State
4 / 24
Subdivision/Plat Name p��
/ K ��1 , crCof / (f/ .Slo h
4 Assessor Parcel No.
. /4 24/6/
Lot
J
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell #No.
/
of Buildings
Z
Sq. Ft./Acre
Depth
/v7. 27
Frontage
Sp.28
7 Set Back -Front
/26
(L S-1
;55
(R)S-2
5
Rear
5
(census Tract
Module No.
Initials
rf
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 #1 above)
Som ego
Business Address
9 Zip
City
State
Phone
(50) 2‘C' g1Q'/
12 Review Required
Plan
Check (Y/N)
Other (YIN)
SEPA
Exempt
(Y/N)
Date
15 Type Work Ei
❑
Bldg
Fire
❑ MH
❑ Demo
' New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
7oched
dia ye., 2-6
X '
('d
10 Applicant Name
Street
_
Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Addition formation
ran 50 ' S-/ 5iiy
p/ans on ii/6
Application Type
(Standard unless
otherwise indicated)
❑ Fast Track
❑ Early Start
Environmental Health
W. 1101 College
Room 200
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑ Commercial;
❑ New Construction;
• Additional structure;
APPLICATION # 4
❑ 1,esidential
pi8ldg alteration/addition
I Release
Release w/cond 1
Hold 2
Mi
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: El Commercial;
N. 811 Jefferson ❑ drainage
El road improvements
Conditions/Comments.
El Residential;
❑ new access/approach;
❑ Flood Plain;
El 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
L
ti -z, Sic- 64 -c.ged