1984, 04-03 Permit App: 84A-2883 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) (m) Department Use Only
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I
Comm
2 Project Address (not Mailing Address) ar Road Name Space Zip
3 City/Communilv �
S� //'''.
State//
GL
Subdivision/ Plat Name _-�¢ -S,
", ice 9/ 1ys�/�/vC'z
4 Assessor Parcel No.
S. - 0 Loc
Lot
5
Block
. it ,t DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2
I Rear
mus Tract
Module No.
Initials
16 Architect Firm Name
-
Street Address
.54):1r
Zip
Clty
State
Phone
( )
Contact Person
Phone If different than above
( )
,
Contractor Firm Name ,fie
Street Address
Zip
City
State
Phone
( )
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 (Y/N)
SEPA Exempt (YIN)
Date
15 Type Work lie Bldg
❑ Fire
❑ MH
❑ Demo
k' New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
( ' .r:9 'f c ;,7 & 7' ) EA -
10 Applicant Name
7 -17te y1i1_ fr. ir-- 2Z5. ---t-'72
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application
This is not a Permit
❑
Type
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
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;
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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-
onditions/Comments•Project
ProjectRepresentative Telephone
Information
Agencies Performing Special Inspection:
1
2
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold