1985, 04-19 Permit App: 00005308 ResidenceBUILDING 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 Mg ast)
AS co 2
Z9 a
(first)
(m)
Dt Use Only
epartmen
�• Comm
2
Project Address not Mailing Address) or Road Name
Y
Space
Zip
3
City/Community
State
Subdivision t Plat Name
4
Assessor Parcel No.
L _ D C C_
'
Lot
Block
13
it it* DEPARTMENT USE ONLY
Sic Code
Zone AAcct.(#
ZoneR
Project No. _
L76
Dwell #
No. of Buildings
Sq. Ft.lAcre
Depth
Frontage
Set Back-Fron, (L)S-1 t
5
(R)S-2 Rear
Census Tract
M ule No.
Initials
L N
r 16
Architect Firm Name
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Contractor Firm Name
Street Address
ZIP
City
State
Phone
Contact Person
License No.
Phone if different than above
8
OwnerlAgent lif different than #1 above)
Business Address
9
Zip,�qq
li
C• Ir
State
Phone
( )
12
Review Required
Plan Check (Y N)
Other (Y/N) SEPA
Exempt (Y/N)
Date
15
Type Work Bldg
❑ Fire
❑ MH
❑ Demo
ew
Add/Alter
1 ❑ Replace
❑ Move
❑ Other
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 0
-1-32
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
i nis is not a Permit
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
❑ Commercial; ❑ Residential
W. 1101 College
K New Construction; ❑ Bldg alteration/addition
Room 200
❑ 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 X 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
1.
0
CU
E
2
0
C
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
C
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