1985, 05-17 Permit App: 00005461 Residence (9 31 o�
- 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
liC�/�9le.� �i?r�f O/ J44•✓ Fbs. Comm
2 Project Address(not Mailing Address)or Road Alame Space Zip
3 Ctyy/Co mm nity �SStttate ( /l Subdivis' /Plat Name ���� /�
:-9 ".n/G -�" J ' /�/if 'd r, /�Cl%''ii'./ _l am'/ C/
4 Assessor Parcel No. Lot Block
4J.7 5 30 / / * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone No. �
5F
� 6
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Fronts e
f9
7 Set Back-Frontk- (L) -1 I (R)S-2 Rear Census Tract Module No.U 1 Initials
�ls
/6) f 1 .; '_ I , JUN a)
* 16 Architect Firm Name
Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name/ ��� Street Address j
(7e7i✓GIP /�/'?J v7, L./ f/ -'4-1 . � 017° �°y /tl'/v
Zip✓ / City j� State Phone 7 �j
Contact Person License No. Phone if different than above
8 Owner/Agent(if different than#1 above) '/,/e& Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) I SEPA Exempt(Y/N) Date
15 Type Work Bldg E MH X New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
iDPNIGE w/ 6,K12 A-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
Mr— lo40 4
2r = 3'171
05 = 4450
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 Release
Early Start Release w/cond 1 Hold 2
❑ Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition �// i 1•
Room 200 ❑ Additional structure;
APPLICATION# ( ✓ v
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; 0 Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
� � (J6es
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson 0 drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments: 1-No c PQvc C Q vi`rvn'$ - f1U\
C I r\ r r3tl c0 Wcf4 _Q i'J ? E. .o. vevvav\j-s (-6 . I I
Ues�- s
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
a
11 I
Project Representative Telephone
Agencies Performing Special Inspection:
1.
Y O
0 --
co
E 2
o O
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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