1984, 08-01 Permit App: 00001518 Residence 1
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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) (first) (m) Department Use Only�a / 2� tI Z S Wile.,-----
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2 Project Address(not Mailing Address)or Road Name Space Zip
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3 City/Community ick State Subdivision/Plat Name
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4 Assessor Parcel No. —'—._• Lot/ 011 Block ii i.
2 2 S q 3 0 $3 74- PTA. -6.f.34Cw -4-
p'Ti arc F'Q * * * DEPARTMENT USE ONLY
5 Sic Code t.* Zone Project No. jpth
� ' 86 Dwell* No.of Buildings Sq.Ft./AcreFrontage
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7 Set Back-Front I4 I(L)S-1 (R)S-2 l Rear -Census Tract I Module No. i ' als
* 16 Architect Firm Name Street Address
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Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Nam4T,sriL
n Street Address
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Zip City 1 State Phone
Contact Person License No. Alar Phone if different than above
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8 Owner/Agent(if different than#1 above) Business Address
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9 Zip �j City State Phone
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12 Review Required Plan Check(YIN) Other(Y/N) I SEPA Exempt(YIN) Date
15 Type Work Bldg ❑ MH VNew ❑ Replace ❑ Other
0 Fire 0 Demo 0 Add/Alter 0 Move
14 Describe Work
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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 nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.) _
illast Track
Early Start Release
Release w/cond 1 Hold 2
NEnvironmental Health ❑ ommercial; Residential
W.1101 Collegeew Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
El 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:
di/g
/Engineers: ❑ Commercial; V esidential; ❑ Flood Plain; i
N.811 Jefferson IDdrainage 04 new access/approach; IDfence; I
❑ road improvements
Conditions/Comments:
0 Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
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u Plan Exam �.:ZGtii*
Fire Prev.
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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