1985, 06-07 Permit App: 00005841 Residence 24 5 3 3 - c4 l - '9q4 _ a9 61
•
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) r (first) (m) I Department Use Only
CI— ( 1 /� (5C' e;e,e_. Re. commI
2 Project Address(not Mailing Address)cr Road Name ` Space Zip
3 !Community State Subdivision/Plat Name
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L F * ,t . DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# ZoneProject No.
Ac _SSzi ( ,
6 Dwell N No.of Buildings Sq.Ft./Acre Depth Frontage 1
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7 Set Back-Front , (L)S-1 (R)S-2 I Conus us Tract Module No. Init als
j 7 2 = ` }f , ..A U1•.1 (Y) .
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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
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Zip City I State Phone
(Cpntact 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(YIN) Other(YIN) SEPA Exempt(YIN) Date
15 Type Work R Bldg C MH q New 7 Replace ❑ Other
C Fire ❑ Demo C. Add/Alter ❑ Move
14 Describe Work
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
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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 d- - ^
W.1101 College 0 New Construction; ❑ Bldg alteration/addition
Room 200 0 Additional s? oiq
ture;/
APP ICATION#
Conditions/Comments: /t'itfi , 777./45 16-,4-f;e& �iVl
❑ 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;
❑ Other
Conditions/Comments:
16
El Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence; AO
0 road improvements r�/�/ p
Conditions/Comments: 7 /Uff'.��0
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
❑ Other:
❑ Plan Exam 1
Fire Prey. !�
Conditions/Comments:
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Project Representative Telephone
NAgencies Performing Special Inspection:
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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