1985, 07-05 Permit App: 00006057 Residence•
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 OOwwner's Name (first) (m) Department Uyetnly
//^^�� �((las�t) ,,y,
tCD t/v.JT I u�lLDln • Rte. Comm
f
2 Project Address (not Mailing A�ddree��sss))� a� Road Name � ^^ Spm Zip
4-flo . -5 I.L/�^ � N/. 97Z17-6
3 City/Community
State I
wdi6L
^t=� Subdivision/Plat Name
-PD'oSet ' S
Parcel No.,
4 Parcel No.
31s4q' 2- 2
V
Lot
3
Block
/
♦ f • DEPARTMENT USE ONLY
5 Sic Code
Zone Act. f/
Zone���
Project No. 6057
6 Dwell If
i
No. of Buildings
/
Sq. Ft./Acre
DepthFrontage
/50
/09
ront
7 Sat Back 30 1 (L)S 1
(R)S-2 I Rear ��
Lenses Tract
Module No.
Initials. ��
16 Architect Firm Name
Street Address
Zip
City
State
•
Phone
Contact person
Phone If different than above
( )
Contractor Firm Name �,,j, � �1+
Cs alOu"b O1,�st�Ltc.t)oL. Co.
Street Address
1)s' lD t lk--‘
Zip
497.0.4
qty
312aKata../
State
wIMS L
Phone
(501) 9z7 -800Z
Contact Persgn
V`'1 is(4�l &La -t
License No.
&.,1 (...a es i ,eo
PhoneIf different than above
( )
S Owner/Agent (if different than pl above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Pian Check (YIN)
an
Other (Y/N) I SEPA Exempt (Y/N)
Date
15 Type Work 2Bidg
0 Fire
❑ MH
0 Demo
l New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work (
I.&• , I Pete cu/&4R4G�
10 Applicant Namg/� �
V-1 1G� QJ ,.,t Uali.t
Street Address
l 1510 CL
11 Zip
g" -r zob
City
ga Lei
State
t.) -4)s.
Phone
lir , ?r,7-00(0?_,
Lender
i%>-w,a - OAcrc -l-
Street ddress
.9/ v1U-lldb—
Zip r
fi z 46
City
SpO�, L�
State
wa6IA
Phone ta �i '
(5-�) 9 '1 DLk
Contact Pe n �T'' k, 1
li,l 1. el `Trb..r � t l
Phone If different than above
)
Additional information (l e•• `— V
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t129- WY E E N E
8/5 =2r-
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
Environmental Health
W. 1101 College
Room 200
r
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either "release' or "release with conditions"
space prior to permit Issuance.)
❑ Commercial; & Residentlai
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
Release
Release
w/cond 1
Hold 2
Fire Prev.
Prf
APPLICATION #
Conditions/Comments'
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone.
❑ CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments-
Engineers:
onditions/Comments-
Engineers: 0 Commercial; 0 ;Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainagenew access/approach; 0 fence;
O road Improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam —ef.
Fire Prev.
Prf
Cond itl ons /Comments •
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indkate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold
1
ADDRESS: 5 VOZ r!Q,{ D1POCFl�� PROJECT M:
General -
▪ Ownership Health
❑Applicant Increased Lot Coverage?
❑ Contractor Addition Bedrooms/
Fixtures?
D Architect Change of Use?
New Septic?
&Address
H Legal Description
Iyparcel Number Unplatted Property?
Lot Depth: Width > 3:1?
(Less than 10 acres)
Plannin
Lot Depth: Width > 4:1?
� (10 acres plus)
Q 'Zoning Lot Size Less than Minimum?
®'Site Plan Segregation of Platted
Property?
O Plat Map Setbacks Less than Required?
Di -emit Description Frontage less than Required?
• Plans Not a Permitted Use in Zone?
D Completeness Rezone, Conditional Use,
Variance Involved or Required?
O Square Footage Commercial Use or Home
Occupation?
O Occupancy Group d 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?
REVIEWED BY:•
Se•a
Underground Tank Over
10,000 Gallons
Commercial Building Over
12,000 Square Feet?
Over 20 Dwelling Units?
Over 40 Parking Spaces? /
Agricultural Building Over be/
Square Feet?
Yes No N/A
7
7
r
7
7-
7
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical
Use Activity?
goeu
DATE: 6--/CJ-
Ly
- " •
2