1985, 04-22 Permit App: 00005047 Residence 27O "
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 Ow 's Name (last) (first) (m) Department Usonly
•-- --7fji✓ Res. V/ Comm
2 Project Address(not Mailing Addr )cr Road Name Space Zip
' 3 City/Communit State bdivision/Plat Name
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Assessor dessor Parcel No. Lot Block
253 �� (-0 ) * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.8 Zone Project No.
6 Dwell4 No.of Buildings Sq.Ft./Acre Depth t Frontage
1 / 1\ b —7O,
7 Set Beck-Front I(L)S-1 (R)S-2 I Rear Census Tract I Module No. Ini' Is C
* 16 Architect Firm Name Street Address
Zip City State Phone
( 1
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
( )
Contact Person License No. Phone if different than above
( )
8 Owner/Agent(if different than 41 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) SEPA Exempt(YIN) Date
15 Type Work V Bldg D MH *V New ❑ Replace • ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
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�0 Applicant Name e Street Address
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e 3 P��11 Zip ACit74A;--7
/ U! �te er / PhonIn e) 773 0O.g
* Lender `/J/ Street Address *
Zip City State Phone
( )
'
Contact Person Phone if different than above
( )
Additional Information
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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
V15/
Release w/cond 1 Hold 2
❑ Environmental Health ❑ Commercial; ❑ Residential T-13I
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure; _.)`aiZ;DtPwv
APPLICATION#
Conditions/Comments:
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; 0 Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
n
E gineers: ❑ Commercial; 7 Residential; Flood Plain; I 161 It AI 115iiiy1
N.811 Jefferson ❑ drainage new access/approach; ❑ fence; ., I•
❑ road improvements �^ 0--2
t
Conditions Com en ?�� �/ � �"..��U e�,! �...� �-`l C�"2. �`. G't i
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
a
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co Project Representative
Telephone
0. Agencies Performing Special Inspection:
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H E 2.
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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
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