1994, 05-29 Permit App: M1694 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 //past)) (first) (m) I Department Use Only
h l.'/—h cv "4-c. L Res. Comm
2 Project Address(not Mailing Address)a-Road Name Space Zip
/Y7 0 7 J S-1--7 99z-).)z
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. Lot Block
Z.
c47 39 * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone �ry Project No. i fl I
6 Dwell N 1 No.of Buildings Sq.Ft./Acre Depth, Frontage ,
Frontage
1 12_ 7 1s '
7 SetBack-Front (L)S-1� G 1 (R)S-2 I Rear��I�) Census Tract Module No. IniRiau K\
l l �J1
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
ga . , ///el / Zo -7 A(- e
Zip / City State Phone
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Contact Person License No. Phone If different than above
e�Co, aighy c -/6l c// (b�' ) ._ c- S yy
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) I SEPA Exempt(Y/N) Date
15 Type Work Bldg ❑ MH ❑ New D Replace ❑ Other
E Fire ❑ Demo X, Add/Alter ❑ Move
14 Describe Work j ( --7G
10 Applicant Name Street Address
11 Zip City State ' Phone
( )
*
Lender Street Address 1 *
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.) r
❑ Fast Track
❑ Early Start Release
Releasesw/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
1.44�1
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure; 9 'F /
APPLICATION#
Conditions/Comments:
❑ Planning/Zoning: 0 Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson 0 Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
O Other
Conditions/Comments:
❑ Engineers: ❑ Commercial; ❑ Residential; 0 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
i°❑ Project Representative Telephone
co 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
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