1984, 06-20 Permit App: 00000799 Pool 1
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) 1 Department Use Only
( f Rm. Comm
2 ProjectAddress(not Mailing Address)cr Road N Space Zip
i 1�wc - '19& `7
3 City/Community State Subdivision/Plat N e
111"
4 Assessor Parcel No. Lot Block
4oS4 —7 `'?0,.... a 2 * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone ..-TProject No. 7�
6 Dwell# No.of Buildings -Sq.Ft./Acre Depth Frontage
( ( 1Z�e 8d
7 Set Back-Front I(L)S-1 (R)S-2 I Rear Census Tract Module No. also
l�s
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
_
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
Zi City State Phone
4rizv8' LkaA _ (9) 49.q IcitE5f
Contact Personn �) License No. Phone If different than above
-'� Cc�� / 3 6r- 1 srigts9 ( ) mL„-
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) I SEPA Exempt(YIN) Date
bl S
15 Type Work ❑ Bldg ❑ MH 0 New ❑ Replace 0 Other
0 Fire 0 Demo 0 Add/Alter 0 Move
14 Describe Work
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 i' I,2„..?,
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.)
111 Fast Track
Early Start Release
Relea-- w/cond 1 Hold 2
v_( Environmental Health ❑ Commercial; Residential
W.1101 College LI/New Construction; ❑ Bldg alteration/addition
Room 200 V Additional structure;
APPLICATION# /4i/ay
,
Conditions/Comments:
Q 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:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson CIdrainage CInew access/approach; CIfence; I
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
•
T—'
El Plan Exam
Fire Prey.
Conditions/Comments:
a
y
O Project Representative Telephone
a Agencies Performing Special Inspection:
1
0
U
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H E
2.
y
E
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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