1985, 05-22 Permit App: 00005642 Residencey
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)
OS-
Department Use Only
Rss. Comm
(not Mailing Address) or Road Nae Space Zip
2 Project Addo m
3 City/Community States Subdivi/Plat Name
U—
4 Assessor Parcel No. , Lot Block
n�� DEPARTMENT USE ONLY
5 Sic Code
Zone Act. M
Zone A S
Project No.
6 Dwell#
No. of Buildings
Sq. Ft./ Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2
Rear
Csnsus Tract
Module No.
Initials
16 Architect Firm Name
Street Address
ZipGty
State
Phone
( )
Contact Person
Phone If different than above
Contractor Firm Name
Street Address
Zip
03
CityState
Phone
eye
Contact
70 IS(
License No.
Phone if different than above
)-9f
8 Owner/Agent (if different than #1 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 Work dg
❑ Fire
❑ MH
❑ Demo
ew
❑ 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
( 1
Additional Information
I r`v1
Application Type
(Standard unless
otherwise indicated)
❑ Fast Track
❑ Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑ Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 F, Additional structure;
APPLICATION # V��
Conditions/ Comments:
a
Planning /Zoning: ❑ Commerci,al; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
Release
Release I w/cond 1 Hold 2
C1
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C: —
_ ❑
Fa
Conditions/ Comments:
Project Representative
Agencies Performing Special Inspection:
1.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Telephone
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Platin;
N. 811 Jefferson ❑ drainage ❑ new access/ approach; ❑ fence;
❑ road improvements
Conditions /Comments:
utilities:
N. 811 Jefferson
Conditions/ Comments:
❑
Other:
❑ Plan Exam
Fire Prev.
C1
U)
C: —
_ ❑
Fa
Conditions/ Comments:
Project Representative
Agencies Performing Special Inspection:
1.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Telephone
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