1984, 06-27 Permit App: 00000199 ResidenceBUILDING 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 Ow 's Name (last) (first) (m)
14ytJ / G ,t)e�i✓
Department Use ly
Res.
Comm
2 Project Address (not Mailing Address) ar Road Name Space Zip
X 19%5" r d i rtµ
3 City/Community
,/)/,� _
State
6/--) u(..
Subdivision /P t Name ���
X Y V/ c--�
4 Parcel No.
� . i c)�,0
� — 44=5—
Lot
,Q
Block
3
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 8
Zone('
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth i
Frontage
7 Set Bads -Front i (L)S-1 /
70Rear
(R)S-2
S 1
()EMUS Tract
Module No.
6
als
16 Architect Firm Name
1 v
I Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
P7 ov
Street Address
Zip
Gty
I State
Phone ]) 4/ 4614
Contact Person
1 c:'+3 W1,44c4_,:-_-,
License No.
114 5C0c3 2, fl Jam`
Phone if different than above
( )
8 Owner/Agent (if different than #1 above) 7—f(t/$S/
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN) I
SEPA Exempt (Y/N)
Date
15 Type Work 1rBldg
Fire
El MH
❑ Demo
)New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
e - I % &A, L. Dlvt C7 •
10 Applicant Name
1 8 ra- 1. 1)1 sn
Street Address
W 3dlo~ C .Dates
11 Ap
Cit _' /
State /
Phone
Lender ,,
l_ ce)LctpvL 6 1 r c�a[c .
Street Address
Zip
City ",-,
. '--D,oke---
State
Phone
( ) 12 a— /
Con Person
.1A__ --:7-k--)1.__-\ `J D ffk.Q c52 -t -t_
Phone if different than above
( )
Additional Information /�
mF� /3016, SF 'C��j
6 _ 4 5r
aCO
m
0.
CO
U
i
H
m
LL
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
❑ ommercial; Residential
New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION #
Conditions/Comments ,.
/ Q
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
O Other
Conditions/Comments.
Engineers: ❑ Commercial;
N. 811 Jefferson ❑ drainage
❑ road improvements
Conditions/Comments•
'Residential;
new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
c
0
E
0
c
Project Representative
Agencies Performing Special Inspection:
1
Telephone
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
Hold 2
Jeir
Conditions/Comments ,.
/ Q
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
O Other
Conditions/Comments.
Engineers: ❑ Commercial;
N. 811 Jefferson ❑ drainage
❑ road improvements
Conditions/Comments•
'Residential;
new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
c
0
E
0
c
Project Representative
Agencies Performing Special Inspection:
1
Telephone
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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