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1984, 07-05 Permit App: 00001045 Barn Addition BUILDING 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 Buildeng and Safety) 1 Owner's Name (last) (first) (m) Department Use Only �u,(//� 64) Fes. Comm 2 Project Address(not Mail' g Ad reel)or Road Space Zip � i5do 5 11 Cl CI 24 ( 3 City/ 'immunity t4JStjjte Subdivision/Plat Name 1--/-01-71.-g--' . 0,-.11.-- 11x-0 V'A u•-) 9(o F r F- 9/20 $s--9 • 4.-. Parcel No. Lot Block 544 - 15 a el 4 * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act.M Zone /[�,p S Project No. f 4,5- 6 Dwell 0 No.of Buildings Sq.Ft./Acre Depth Frontage 1 01( 1 1 1 7 Set Back-Front..� (L)S-1 R)S-2 Rear Census Tract Module No. Initials ,1 y�/� )k' /t ' I !`l-/1 f \j0 1r/ . * 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 01 above) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check(Y/N) Other(Y/N) [SEPA Exempt(Y/N) Date 1 Work ❑ Bldg 0 MH 0 New 0 Replace 0 Other 0 Fire 0 Demo L=}---"Add/Alter 0 Move 14 Descri Wgrk `4 y Z4 t -- 33co 10 p ' nt N Street Address i a4t--e Z(/ - WOO el '/-S-A%' 1 11 Zip City State Phone Y 99 Z-i r�� (S'vy) 9z8= 1 v * Lender Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Information DEPARTMENT APPROVALS • This is not a Permit Application Type (Standard unless (Ind•icated approvals required in either"release"or"release with conditions" otherwise indicated) spate prior to permit issuance.) / Fast Track 0 Early Start Release _ Release w/cond 1 Hold 2 Environmental Health ❑ Commercial; ❑ Residential 1 a W.1101 College ❑ New Construction; ❑ Bldg alteration/addition Imo`i Room 200 ❑ Additional structure; ``� ,i APPLICATION# Conditions/Comments: El Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage; N.721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; ❑ use/zone; ❑ CU,variance,zone change;shoreline; ❑ fence; ❑ Other Conditions/Comments: O Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; N.811 Jefferson ❑ drainage ❑ new access/approach; 0 fence; ❑ road improvements Conditions/Comments: Utilities: N.811 Jefferson Conditions/Comments: Other: ❑ Plan Exam Fire Prey. Conditions/Comments: ci c❑ Project Representative Telephone c0. Agencies Performing Special Inspection: c 1. 0 O 00 H E 2 O LL. c 3. 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold £ , ! . 1 . ! . / ® ' i , ' . / . . i . . . t i . , ; . . . ' ' } } � \ « ' ' / , | ; . § i ) y . . ) fi ) ; '! '| ; i i' | + 11\ - ) , C '. i . ` !) ; ' ] i . , !i\ ' ] 1 | , !fk} ' ; i | 1 i , i i ' ) � ! I ) } I i i ; ] 4 ! ) r | } | \ " ! ' ' | 1 i i 1 ; ; ^ ; ; i : , ) { ; ; , ) ' . , 1 ,22, ,, , , , , , • \ � . ! ] , 2 1 , 2 1 a � • . , 1 1 ,2 1 „ III , ...N._ , | , , , , . L. < , › ; 1, 1 , i , i , , } , \ 2 , , ) ! -� ' ) ; \ , ,, i ! " l ' i ���1, .. ..,,„, • ?. a `, ; . ; ... sz , , , } . ,, ! , , 1 | � � " ' ' . 1, 1 11 ; 1 , i 1 \ . ; I ; , ! t I } 1 1 I I II } . 1 \ ' ! l : , , ; : ; ; s i 1 I 1, I 1 ; 1 1 ! ! . I, 1 ! i ] . ! . . } | 1 ! ; . ! ! | ! } ! } } , | ! } , . ' } ; . , , : . . . y . ® (\ ` » \�\ j < ! |j | . ) y , .) « . . / »» ©®r ! } / »; t. | R ��✓ ��