1984, 07-06 Permit App: 00001173 Garage / 1 • �4,L - 3u, Cl
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 Building and Safety)
1 Owner's Name ( t) C(first) (m) I Department Use Only
Rt. Comm
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2 Proj Address(not Mailing dress) Road Name ( S ace Zip
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3 City/Communit State 1 Subdivision/Plat Name
4 Ass Parcel No. Lot Block V.
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5 Sic Code Zone ict.M Zone Project No.
6 Dwell#
I No.of Buildings Sq.Ft./Acre Depth ( Frop(�ge
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7 Set Back-Front (L)S-1 (FOS-2 Rear Census Tract Module No. Initials
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* 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(YIN) Date
15 Type Work >i Bldg ❑ MH ;lc New 10Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
06(0.44-6,E 2 4 q -z,
10 Applicant Name Street Address
11 Zip City State - Phone
( )
* 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 (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Track
❑ Early Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
0 Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage; .i
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; •
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
0 Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
a
❑ Project Representative Telephone
Agencies Performing Special Inspection:
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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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