1984, 11-28 Permit App: 00003569 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 (fast) (first) (m)
Department Use Only
Fes. ✓ Comm
i r
2 Project Address (not Mailing Address) or Road Name Space Zip
`� k'•
t
3 City/Community Stat//e Subdivision/ Plat ISme
y
4 Assessor Parc&I No.•7 Lot Block
30 �-- I * * * DEPARTMENT USE ONLY
5 Sic Code
Zone Act. ff
Zone Project
No. � e; V1
6 Dwell N
No. of Buildings
Sq. Ft. IAcre
Depth
Frontage I
t
130
((1
7 Set Back-Front(L)S-1
(L)S-1
(R)S-2 (
Rear
Census Tract Module No.
Initials
50
�0
C�
�—
16 Architect Firm Name
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Contractor Firm Name
Street Address
Zip
-City
�4
State G `3 \
Phone ) — �3 2—
Contact Person Person
License No.
Phone if different than above
a
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/ N)
Other (YIN) SEPA
Exempt (Y/N)
Date
15 Type Work Bldg
❑ MH
New
ElReplace
1-1Other
❑ Fire
❑ Demo
ElAdd/Alter
❑ Move
14 Describe Work
10 Applicant Name
Street Address
11 Zip
�2C?b
City
5�n
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Ad7ditiponal ormation
S
I
I DEPARTMENT APPROVALS
I i inalcate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
I nls 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
W. 1101 College
Room 200
❑ Commercial; ❑ Residential S, v
Ri New Construction; ❑ Bldg alteration/addition �Z $
❑ Additional structure;
APPLICATION #�-12Y3
(! `
Conditions/ Comments:
'aa
❑
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; 6/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
Ca
E
O
2.
C
3.
I i inalcate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
SIO
00.