1985, 04-19 Permit App: 00005305 Residence214
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 a
L)
(I t)
,
(first) (m)
r
Department Use Only
Res. I Comm
2 Project Address (not Mailing Address) or Road Name
Space Zip
3 City/Community
State
Subdivision/ lat Name
4 Assessor Parcel No.
6^
Lot
Block
* * + DEPARTMENT USE ONLY
5 Sic Code
Zone Act. #
ZonePC, j Project
No.
6 Dwell #
No. of ButlqingsC__Sq.
V14
Ft./ Acre
Lg)
Depth���j �
Frontage
7 Set Back -Front
(
J(R)S-2IR2
/
L L'
Census Tract
Module No.
I
Initials
�'J l�
16 Architect Firm Name
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Contractor
Street Address
Zip
City
State
Phone
Contact Person
License No.
Phone if different than above
8 Own#N,Agent (if different than #1 above)
/�
Business Address
9
CityState
Phone
'
0
12 Review Required
Plan Check (YIN)
Other (Y/N) SEPA
Exempt (YIN)
Date
15 Type Work
g Bldg
Fire
❑ MH
❑ Demo
77Add/Alter—
❑ Replace
❑ Move
❑ Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City
State
Phone
LenderStreet
Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
F ; C[pbie
.
T,,
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
I nls Is not a Hermit
Application Type
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
Release
Release w/cond 1 Hold 2
Environmental Health
W. 1101 College
Room 200
Residential
❑ Commercial;�ED
❑ New Construction; Bldg alteration/addition `J
❑ Additional structure;
APPLICATION #
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; ❑ Flood Plain;
N. 811 Jefferson
❑ drainage ❑ new access/ approach; ❑ fence;
Conditions/ Comments:
❑ road improvements
❑
Utilities:
N. 811 Jefferson
Conditions/ Comments:
❑
Other:
❑
Plan Exam,
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
C
O
1.
m
E
2
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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