1985, 05-22 Permit App: 00005648 Residence ti
. ',
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
j///>� y�, (last) ///��, (first) (m) Depart Only
/'r L OPS L Lit. j 4f9g �` Fes. Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
. /3.40 - to i ? `1 74 Q/2
3 Cit muuniity T State Subdivision/Plat Name
R)44v,�""p'. _ 60/4 . .‹ `°cl i -k— 116.4„&c. ,
4 Assessor Parcel No. Lot I Block
2–P5 vi/ — coal -rhfe * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No. V
56i1
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ I lSl• -72 FO. 2L
7 Set Back-Front (L)S-1 (R)S-2 Rear Census Tract Module No. Initials
35 & /6 j alt-te-e)
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
M14-g<E, z 4-49 2-g . 5--- 9707S- .
Zip ^ q,93 City Sex-- State 4.14- . Phon( ) W
el-30A 61,9074
Contact Person License No. Phone if different than above
( )Vs ._98O> ( o )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(YIN) l1 SEPA Exempt(Y/N) Date
`
15 Type Work Lq/Bidg ❑ MH New ❑ Replace ❑ Other
.- Fire 0 Demo ❑ 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
/3X /Y G2 4.. APS
PIE = Mr
620& - qg
DEPARTMENT APPROVALS
This is not a 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
Environmental Health ❑ Commercial; ❑ Residential /' ' s—, if
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition thy, /,/
Room 200 ❑ Additional structure;
APPLICATION# S7,<OD/
Conditions/Comments:
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; 0 Flood Plain; S ��
. N.811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
111
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
a.
!❑
co
Project Representative Telephone
ca Agencies Performing Special Inspection:
O c 1
U '—
fd
~ E 2.
y o
o C
LL
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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