1984, 04-24 Permit App: 84A-3721 Residence 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
___ 1",_-"i/,, : ,f Rs. Comm
2 Project Address(not Mailing Address)or Road Name S e Zip
3 City/Community State Subdivision/Plat Name
.5743 Z6,. e. 44a y '„,,, To R ,-,.._.,, 'S "„e7/97-72."---,
,
4 Assessor Parcel No. Lot Block
22— 12..
.1 / 2 * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone f Project No.
f/Ct ,
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
1 110
7 Set Bads-Front t (L)S-1 (R)S-2 Rear Census Tract Module No. Initials
4-.( ' ,
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
G a. ,fr eft ,.-? ,$7L:” /1/, /5///.5- 4,yrzzA .._ _
Zip City State Phone
4 3 0?— 9 74 ' SPo z-„,‹.. Gva.• (.559 ) .,,e,‘,.. a
Contact Person License No. „2 Phone if different than above
G 4C-1"e, /e2(e-ri e/It A 70/ol ( )
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(Y/N) Date
// ' YC
15 Type Work ..2 Bldg ❑ MH 1 /New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work ,C
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
• 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
Release w/cond 1 Hold 2
12/1 Environmental Health ❑ Commercial; Residential /
W.1101 College E;-'New Construction; ❑ Bldg alteration/addition ✓
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Ci mmen i/����p�
- tr/!/i
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; 0 fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; E1 Residential; ❑ Flood Plain; �y
L/
N.811 Jefferson ❑ drainage (2(new access/approach; 0 fence; /
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
0.
c
c�
•° Project Representative Telephone
ca Agencies Performing Special Inspection:
c 1.
Y O
E 2
a) o
m c
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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