Broadway E 13823 Circle K Corp Canopy
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6UILDINC PERMIT APPLICATION WORKSHEET
RLEASE PFiINT ANO COMPLETE ONLY THOSE PARTS OF THE FORM YOD UNDERSTAND
~ (Piease return Ihls,original and your'butldinA plans,to the Qepanment of Bullding and Safety)
~ 1 Owmar'eNeme p83t) (hrst! (ml OeparirnenllbeOnfy
Cl dQ e'. le- & ~ Comm
? Projed Adlrees (not Ma~lmg AQdresd) a Road Namd' SPace Zfp
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s Paroet No lot etock
~ ~ L ~ w DEPARTMENT USE ONlY t s*
3 Gode Zone Act A Zme ~ P►oJect No
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8 Owell A No of 8uildtnps Sq Ft lAcre pepth - Frontage `
7 Set Badk-From (L,)S-l (RW2 Rear ONnsus Trod ~ MoOute,No Inlllala
~ 16 Ardhltecy Firm Name - Street Addrese '
Zlp ply Stste Pftone
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ComteG Pe►son Phone li dlHerent then ebave
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Qortt►aetw Flrm,Neme 8treet ddr~es9
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no Phone Ir alfrerenc man abova
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8 Owner/AQent pf dlHerent tAsn q1 ebuve) Buelnees Addresa
9 Zip C!ty State Phona
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~ 12 Review Reqljl►ed Pien Cttsdc (Y!N) Other (YIN! SEPA Exi t(Y1N)
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15 Type Work 0 Bldg 0 MH ~ Cl New 0 Reptwe ~ pther
D Fire p pemo r) MdlAlter ❑ Move _
14 DoctibeVYW'k C"Joel
10 Appticant Neme Slreet Addrwe
11 ZiD - Gly Slate Phpne
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* lArtdst i Sireet Addrees *
Zlp Gry State ' Phwne
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Gbntatt PersOn, Phone if ditterent than above
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DEPARTMENT APPROVALS
- This is not a Permit
AppllcaNon Type
(Standard untess (Indicated appravals requlred In either °release" or'release wlth conditiong•
otherwl8e indfceted) space prior to permit,iS9U8RC8 )
' ❑ FastTrach '
0 Esrly Start Re1~ Releaee
w/cond 1, Hold 2
EnvJronmenlel Health C) Comme►cial. 13 Residentlal
W 1101 Cpllege ❑ New Construction, ❑ 81dg alterationleddltlon
Room 200 Q, Addittonal atructure,
~ APPLICATION q
CondltlonslComments
Planning/Zoning O Commercial. 0 Cert of Exemptfon, ❑ Frontege,
N 721 Jetferson ❑ Seibacks, Cl,lot wld, 0 lot size, O use/zone,
O CU, verianoe, zone chan8e, shoreline, O tence,
O Other -
4
- CorrditionslComments
~
{n - - -
r~ , - - -
~
L' 2T ~ EngInmere: ❑ Commercial, ❑ Reeldentlel, O Flood Plain.
N 811 Jeltetson D drainage f:] new access/approach, O' tence.
~ O road improvements
~ Condltlons/Comments _
t
~
i ~ - •
~ utiun@s
~ N 811 Jeffersoo Candltlons/Comments
V, -
~ - ,
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~
OMer:
Plen Exem
Fire Rrev.
Conditlona/Comments -
a - - - _
a~
ro Project Representative .Telephone _
~ Agencies Performing Special Inspection
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1 Iredkste ebove or ettach condltlons refefive to Ilnal aa oullt approval
2 Indlcate ebove or ettecA reasone tor hold