1984, 08-07 Permit App: 00001642 Poultry BldgBUILDING 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, ( )
meet Use Only
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FIs.
Comm
2 Project Address (not Mailing ) Address . Road ame Space Zip
•
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.
3 City/Community
State
Subdivision/ Plat Name
4 Assessor
Parcel No.
32p
9 S S Z - o32,
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Fronta e
Set Back -Front
(L)S-1
(R)S-2
Rear
I7
Census Tract
Module No.
Initials
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)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
I SEPA Exempt (Y/N)
Date
( 15 Type Work T� Bldg
/❑ Fire
❑ MH
❑ Demo
New
❑ Add/Alter
IE Replace
❑ Move
❑ Other
14 Describe Work %�j� �� % Q' ns- 7 u
1 °L„ 1 YvYV . 2- /` (m )
10 Applicant Nam
,___62 44 !i&//%t
Street Address
407 / 4��
11 Zip City
1 /kt
State
P,c'sW
Phone
(SO?) ?d 1-/- 7 '
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
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7 /5 25---
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a.cpe432
DEPARTMENT APPROVALS
As_
❑
❑
1
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
e
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial;
W. 1101 College ❑ New Construction;
Room 200 ❑ Additional s
❑ Residential
❑ Bldg alter tion/addition
ctur
;i
APPLICATION #
J
Conditions/Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
6f l (g-/
0 CU, variance, zone change; shoreline; 0 fence;
0 Other•
�_
Conditions/Comments: A ' r�f-C 4e / -Z Z' ✓ � 7,z -i.,,_,,,..( i
A4:,, F
/.
❑
Engineers: 0 Commercial; ❑ Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new 0 fence;
I
access/approach;
0 road improvements
Conditions/Comments.
❑
Utilities:
N. 811 Jefferson
Conditions/Comments •
❑
Other:
Plan Exam
?,
Fire Prey.
L
eT
Conditions/Comments: -� �� (� S�� =-�ICcX
TG iNS- Ztom r� v'2o 1J
IInformation ❑l
Project Representative Telephone
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
(2 b P ---r)
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