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1985, 05-22 Permit App: 00005641 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 OwneX',e (last) (first) (m) Department UZ Only Res. Comm 2 Project Address (not Mailing Address) or Road Name Space Zip 3 City/Communit f/ State �A'/n Subdivision/ Plat Name ' / 4 Assessor Parcel No. C# C l Lot Block tr// v�+, I H CLQ t it t DEPARTMENT USE ONLY tr it 5 Sic Code Zone Act. Zone C Project No. 6 Dwell M No. of Buildings Sq. Ft./ Acre Depth Frontage 7 Set Back -Front (L)S 1 (R)S-2 Rear Census Tract Module No. Initials 16 Architect Firm Name Street Address Zip City State Phone l ) Contact Person Phone If different than above Contractor Firm Name M C iLD Street Address C- - Sum c, Zip I d3f'G2-. City State Phone Contact Perso 'go's License No. : :Z ,J -7 Phone if different than above 8 Owner/Agent (if different than qt above) Business Address 9 Zip City State Phone 12 Review Required Plan Check (Y/N) Other (Y/N) SEPA Exempt (Y/N) Date 15 Type WorkBldg ❑ Fire ❑ MH ElDemo New Add/Alter 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 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 (Indicated approvals required in either "release" or "release with conditions" otherwise indicated) space prior to permit issuance.) F-] Fast Track Early Start Relase I Release w/ceond 1 Hold 2 Environmental Health ❑ Commercial; ❑ Residential Z .5- W. 1101 College P. New Construction; ❑ Bldg alteration /addition Room 200 ❑ Additional structure; APPLICATION # Conditions/ Comments: El 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; I N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence; - ❑ road improvements Conditions /Comments: Utilities: N. 811 Jefferson Conditions/ Comments: Other: Plan Exam Fire Prev. Conditions/ Comments: i �❑ Project Representative Telephone i Agencies Performing Special Inspection: 0 1. o s � E 2 o s � 3. 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold 0 YL' //11 Gv - - � 5 �- 0 f� _D-:: 2 �l �- --- ON A07-41 D-3a34-- Sp�L 35©L`r m i v 0 YL' //11 Gv - - � 5 �- 0 f� _D-:: 2 �l �- --- ON A07-41 D-3a34-- Sp�L 35©L`r m i