1985, 04-18 Permit App: 00004999 AdditionBUILDING 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)
t.di 1 So k -v
2 Project Address (not Mailing Address) ut Road Name
E, 11 d1 7 5,.J vi
3 City/Community
4 Assessor Parcel.
335 ?,(//2_
(first) (m) Department
nye Only
Rt. Res. Comm
Space Zip
erdlrfL'f, 1S- Add
Lot
State
CC-54presi
1
5 Sic Code 1 Zone Act. #
Zone
Block
f
e-
SubdivlsionlPlat Name
♦ * * DEPARTMENT USE ONLY * * *
Project No.
6 Dwell*
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2 l Rear
Census Tract
Module No.
Initials
16 Architect Flrm Name 1 Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Flrm Name
EA; 1�✓
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone if different than above
( )
8 Owner/Agent (if different than 01 above)
Business Address
9 Zip
12 Review Required
City
Plan Check (Y/ N)
State
Phone
(5619
Other (Y/N) I SEPA Exempt (Y/N)
Date
15 Type Work
E BIdg
❑ Fire
❑ MH
❑ Demo
❑New
1!! Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work •
/2' X 46, Add res;fc/fwee. 5,5-'2
�?7
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
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions/Comments•
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
V
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
O Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments•
Engineers:
N. 811 Jefferson
Conditions/Comments•
❑ Commercial;
O drainage
❑ road improvements
❑ Residential;
❑ new access/approach;
❑ Flood Plain;
O fence;
El
Utilities:
N. 811 Jefferson
Conditions/ Comments'
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
c
❑ Project Representative
U
ma Agencies Performing Special Inspection:
c
O R al
E
,1 o
`n
u
Telephone
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Release
Release
w/cond 1.1
Hold 2
rill
V
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
O Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments•
Engineers:
N. 811 Jefferson
Conditions/Comments•
❑ Commercial;
O drainage
❑ road improvements
❑ Residential;
❑ new access/approach;
❑ Flood Plain;
O fence;
El
Utilities:
N. 811 Jefferson
Conditions/ Comments'
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
c
❑ Project Representative
U
ma Agencies Performing Special Inspection:
c
O R al
E
,1 o
`n
u
Telephone
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold