1984, 06-28 Permit App: 00000347 ResidenceBUILDING 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)
Go L Da.) c,( j r Co cu re ci C%J O,(/ CO
Department Use Only
✓ Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
.4c. o d- Ica bc5D12- ..F F - 0
3 City/Community
Sp0KAu.E.
State
UJ 41,
Subdivision/Plat Name
Po, WEAaas q S r' I a�0-1.6Jt>
4 Assessor Parcel No.
4-5 ''.a (D(
LotBlock
/
f
* . . DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No. '774{
7
6 Dwell $
k
No. of Buildings
1
Sq. Ft./Acre
Depth
lSv
Frontage
k c5a
7 Set Back -Front I(L S-1
(R)S-2
j Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
GOC DENC,cg.S / COA/S-M.JGTro Co ,
Street Address
E. o) 704/ 6 -'Lc Rb.
Zip 9 9.,)O 8
city Spa A to E
State I v'V 3
Phon (
sal'' ) 9‘‘--- CEJ CJ 1 f
Contact Person
„/osEph toy
License No.
£)3.0} 60lcEcc/ 7.ra8
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)
SEPA Exempt (Y/N)
Date
15 Type Work Of Bldg
❑ Fire
❑ MH
0 Demo
-7 New
- Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work
.S i iv 5•L r m, ii ,Q.c t, v.E ivC hJi..V;74 diE1> Gid df 19 6..C:
10 Applicant Name
— S /M2 —
Street Address
11 Zip
City
State
Phone
( )
Lender
COL V )41B/%4 S'EAe✓, cttr t9%D,ei.T, Co
Street Address
iV . .30C 4AZG0•Vnlg' RD
Zip
9 9 a 6 .
City
5 po ra,v�
State Phone
w n (so?) ?c)..)- ).2 a 0
Contact Person Phone if different than above
.-Det/00 ,./0 Lh N1 oi✓ ( )
Additional Information
4,1_12_
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
Thiele nota Permit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions/Comments.
❑ fLommerclal; leclesidential
New Construction; ❑ Bldg alteration/addition
O Additional structure;�f'
APPLICATION # fr.
V V.S7O
'elease
Release
w/cond 1
Hold 2
inwQb•
•
0
Planning/zoning: 0 Commercial> 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson O Setbacks; 0 lot w/d; 0 lot size; 0 use/zone.
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments•
Engineers: 0 Commercial;�/R�idential; 0 Flood Plain;
N. 811 Jefferson 0 drainage IliieWaccess/approach; 0 fence;
O road Improvements
Conditions /Com menta -
0
Utilities:
N. 811 Jefferson
Conditions/Com ments•
0
0
Other: •
Plan Exam
Fire Prev.
Cond itlons /Comments
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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