HomeMy WebLinkAbout1984, 09-12 Permit App: 00002311 Addition ..l
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\ 'Y BUILDING PERMIT APPLICATION WORKSHEET
o\PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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(Please return this original and your building plans to the Department of Building and Safety)
1 ,owner's Name (last) (first) (m) I Department Use Only
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2 Project Address(not Mailing Address)or Road Name Space Zip
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3 City/Community St Subdivision/Plat Name
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4 Assessor Parcel No. Lot Block
t4 5+ Z—611,¢�j * * * DEPARTMENT USE ONLY
5 Sic Code T Zone Act.#y ` Zone Project No.
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6 Dwell ff No.of Buildings Sq.Ft./Acre Depth Frontage
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7 Set Back-Front (L)S-1 l(R)S-2 Rear Dbnsus Tract Module No.
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* 16 Architect Firm Name
/ I Street Address
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Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City 1 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(YIN) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg 0 MH New 0 Replace 0 Other
0 Fire 0 Demo it Ad/d/Alter 0 Move
14 Describe Work _�r
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10 Applicant,-�e / eet Addres
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11 Zip City State Phone c-</T' s.
79
*
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above —
( )
Additional Information
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DEPARTMENT APPROVALS
This is not a Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
Fast Track
111Rase
e Early Start I s w)ond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition 7 /
Room 200 ❑ Additional tructure;
APPLICATION#Additional
Conditions/Comments:
111 Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; E lot w/d; ❑ lot size; 0 use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
0.
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Project Representative Telephone
n Agencies Performing Special Inspection:
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H E 2
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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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