1985, 05-09 Permit App: 00005330 ShedBUILDING 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)
)first) (mj_ Department Use Only
1 Owner's Name (last)
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2 Project Address (not Mailing Address) cr R6ad Name Space Zip
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3 City/Community /
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.
State
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Subdivision/ Plat Name
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4 r Parcel No.
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Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No. 0
6 Dwell #
1
No. of Buildings
7--
Sq. Ft./Acre
Depth i +
15 1 —
Frontage
(I I
7 Setac -��� t
I (L)S-1 /
(R)S-2
L Rear _
Census Tract
Module No.
Initials
J m .
16 Architect Firm Name
1
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
I 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 (YIN)
SEPA Exempt (Y/N)
Date
15 Type Work )g Bldg
❑ Fire
❑ MH
❑ Demo
Ed, New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work-' l i 1 2_ 2 4
10 Applicant Name
Street Address
11 Zip
City
State
Phone(c I
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f // ( - (/ 'J F
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
•
❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Early Start
r
Release
Release) w/cond 1
Hold
Environmental
2
Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
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S'
APPLICATION #
Conditions/Comments:
•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
1
J
_J
❑ CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
❑
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence;
I
I
0 road improvements
Conditions /Comments:
❑
Utilities:
N. 811 Jefferson
Conditions /Comments •
❑
Other:
I
I I
Plan Exam
Fire
•
Prev.
Conditions/Comments•
1 Information ❑
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
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