1985, 11-18 Permit App: 00008769 Siding "4--s .-1° j'.. - '7/4/11--- 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)
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1 Owner's Name (last) / t�) (m Department Use Only
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2 Project Address(not Matingrese)or Road Name Space Zip
3 CityICommuni ���� State Su siortlPlat Name
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4 Assessor Pa No. Lot 1 Block
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5 Sic Code Zone Act.0 Zone Project No. 01
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6 Dwell it No.of Buildings Sq.Ft./Acre Depth Frontage
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7 Set Back-Front (L)S-1 (R)S-2 l Rear Census Tract Module No. Initials
* 16 Architect Firm Name Street Address *
Zip City State Phone
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Contact Person Phone If different than above
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Contractor F/11-m Name ) Street Address
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Zip City State Phone(5-0q )
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,Contact Person License No. Phone If different than above
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8 Owner/Age (if different than 01 e) Business Address
9 Zip City State Phone
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12 Review Required Plan Check(YIN) Other(YIN) l SEPA Exempt(YIN) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ,$I Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move r��o I b--
14 Describe Work
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10 Applicant Name Street Address
11 Zip City State Phone
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* Lender Street Address
Zip City State Phone
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Contact Person Phone if different than above
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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
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
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
11_7[11❑ Project Representative Telephone
ca 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