1984, 04-10 Permit App: 84A-3392 Residence I
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) I Department Use Only
3 V\ V\`k.f v 0,j-* 1 ibs. Comm
2 Project Address(not+Mailing Address)cr Road Name , £ Space Zip
1
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3 CIty/Community State Subdivision/Plat lame
t%. , o. e-.. (,A) d v,at el o 4' ;ate
4 Assessor Parcel No. Lot Block
32 54 t _ :1#0*-) r") ' * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No.
.i-tom.
X 6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage ,
T 7 Set Back-Front 1 I(L)S-1 I (R)S-2 # I Rear Census Tract Module No. Initials
* 16 Architect Firm Name *
I t I Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm NameStreet Address
VA 4f""''f,.. '-e r v.'s 4'"`£' S 1-\23 Of--,..,A i Q^.A•`01:iyI
Zip CityState Phone
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Contact Person License No. Phone different than above
raxt \IN OOH 1 la E x`12`) ( )
8 Owner/Agent(if different than#1 above) r '141.6"'
, Business Address
' 9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) I SEPA Exempt(YIN) Date
15 Type Workdldg ❑ MH New ❑ Replace ❑ Other
❑ Fire 0 Demo ❑ Add/Alter ❑ Move
14 Describe Work
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
Lender Street Address
F4- K
Zip City State Phone
Contact Person Phone if different than above
Additional Information
DEPARTMENT APPROVALS
This is nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Track
❑ Early Start Release
Release w/cond 1 Hold 2
eti Environmental Health ❑ Commercial; Residential
W.1101 College 12/ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional jstructure;
APPLICATION# g /st6 —J-
Conditions/Comments: zh. .&/ e 1>
❑ 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; 7�J
N.811 Jefferson ❑ drainage Vnew access/approach; ❑ fence; /, / I
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ T Plan Exam
Fire Prey.
Conditions/Comments:
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7.3
Project Representative
Telephone
Agencies Performing Special Inspection:
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F- E 2
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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