1984, 11-09 Permit App: 00003290 AdditionBUILDING 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
Res. Comm
2 Project Address (not Mailing Address) or Road NamvL1
717
Space
Zip
3 Cit /Community
D
State
Subdivision/ Plat Name
//i/LTJ
4 Assessor Pircel No.
33 5+/ D 3a 3
Lot
Block
3
* * DEPARTMENT USE ONLY
5 Sic Code
Zone Act. #
Zone
Project
No.
6 Dwell #
No. of Buildings
Sq. Ft./ Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2
Rear
ell
Census Tract
Module No.
Initials
C(
16 Architect Firm Name
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
( I
Contractor Firm Name
Street Address
Zi �
Ciry
_
State
Phone
Contact Person
License No.
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
g Zip
City
State
Phone
12 Review Required
Plan Check (YIN)
Other (YIN) SEPA
Exempt (Y/N)
Date
15 Type Work
❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
i7-Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
/t"_' "
suivroom
edc
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
I
AI
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 ❑ Additional structure;
APPLICATION #
Conditions/ Comments: S"c% Sewr,*'
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ fot 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;
❑ road improvements
Conditions/ Comments:
Utilities:
N. 811 Jefferson
Conditions/ Comments:
O I I Other:
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Y O
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Co M
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Plan Exam
Fire Prev.
Conditions/Comments:
Project Representative
Agencies Performing Special Inspection:
2.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
.Y .
Release
Release w/cond 1
Hold 2
Telephone
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