1985, 06-17 Permit App: 00850690 MH 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 (last) (first) (m) 1 Department IJ Only
1 � f}/)7 a) (�nJ t� .7)AL 1< 14 Res. Comm
2 Project Address(not Mailing Address)a Road Name Space Zip
N t.125 (QOD LAtunl PoA ra Q*2 l&,
3 CIty/Community State Subdivision/Plat Name
SCbA 6. ivHs 0PPoQTw rry SEE An -'cii O LEGAL
4 Assessor Parcel No. Lot Block
< — 1 C 7/y / �r)� it ,t * DEPARTMENT USE ONLY ,t * * —
5 Sic Code 7Zoone Act.# Zone Project No.
e-6/'esisAKB AG5u e ! _
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ !
`
7 Set Back-Frontm I(L)S-1Q (R)S-2 f 1 Rear3Census Tract I Module No. Initials
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
It ( )
Contact Person License No. Phone if different than above
( )
8 Owner/Agent(if different than#1 above) Bisiness Address
f X.,E A jiR rn r» ani 2 mac'/2 J23 (�f1I ) uJ/99
9 Zip City State Phone
9 a (o Srpa ' A� WAST t (3 ) 9A. 8' — C) g.S"cZ
12 Review Required Plan Check(Y/N) Other(Y/N) I SEPA Exempt(Y/N) Date
P 15 Type Work ❑ Bldg fIMH 41.-""-New ❑ Replace El Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
DOu8LE` cur 10E /-lc''30L& 1101.1E- 66, X 28
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
NEvEr2 AaPPo✓CD FOR FiiIAL I'JS7Ac.LA7 w e Ik—ALT/I•— fti7 , r
7 g- ri ... -._
DEPARTMENT APPROVALS
This is nota 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 (p-o'g!
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition n„D
Room 200 ❑ Additional structure; �i
APPLICATION# � 6 !/�v
Conditions/Comments:
O Planning/Zoning: ❑ Commercial; 0 Cert.of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Ot er
Conditions/Comments: /8l--F6 (A) (B)
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
. N.811 Jefferson ❑ drainage 0 new access/approach; ❑ fence;
0 road improvements /(I
Conditions/Comments: /rAi^ i 36
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
ri
`--°❑ Project Representative Telephone
CD
Agencies Performing Special Inspection:
co
Y o 1•
� m
E 2
LL
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
ADDRESS: I\/ i/25WevoiAWN a PROJECT #:
General - Yes No N/A
.Ownership Health
❑ Applicant Increased Lot Coverage?
❑ Contractor Addition Bedrooms/
Fixtures?
❑ Architect Change of Use? _/
New Septic? y
O< ddress -
❑ Legal Description Plannin.
8 arcel Number Unplatted Property ? v
Lot Depth: Width > 3: 1? _
(Less than 10 acres)
Lot Depth: Width > 4:1?
(10 acres plus)
'Zoning Lot Size Less than Minimum?
Ei Site Plan Segregation of Platted
Property?
�
❑ Plat Map Setbacks Less than Required?
'Permit Description - Frontage less than Required?
❑ Plans Not a Permitted Use in Zone?
❑ Completeness Rezone, Conditional Use. ✓
Variance Involved or Required?
❑ Square Footage Commercial Use or Home
Occupation?
❑ Occupancy Group b Type More than One Residence?
0 Departmental Releases Adjacent to a Required
and Conditions - Shoreline?
En.ineerin.
New Access/Approach?
Private or Unmaintained
County- Road?
Se'a
Underground Tank Over
10,000 Gallons ✓
Commercial Building Over /
12,000 Square Feet? i�
Over 20 Dwelling Units?
Over 40 Parking Spaces? J
Agricultural Building Over ✓/
20,000 Square Feet?
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical
Use Activity?
REVIEWED BY :. C/ 1'Lti DATE : e•,-/7-F...S