1985, 06-07 Permit App: 00005834 Residence 4 R
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
rr r(last) (first) (m) I Department Use Only
u(.,. /L_ rJ• V ?MCC CC //t''C- Fos. Comm
2 Project Address(not Mailing Address)cr Road Name Space Zip
2 /Ail /L/ — Y. �n-.-. C'PGIIr T" yC1C
3 City/Community State Subdivision/Plat Name
�S/'U K/4't" i--C/.eY /=424.s7- 6 Aoe,ars .c-ovex)
4 Assessor Parcel No. Lot Block
J 3 54 $ - 1 ^01
/ * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.fl Zone (7 _g- Project No. ) 34
6 Dwell 0 No.of Buildings Sq.Ft./Acre Depth/ Frontage
` /
/ / 6 eCi
7 Set Back-Front (L)S-1 (R)S-2 Rear Census Tract I Module No. Initials
.31:x / I ar /y I4 _ , .r ON m
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
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Zip CityState Phone
F9'z/ iii--� tig-e c y// ( ��y ciev
Cont Person License No. Phone if different than above
a 1 / x:172—S4S - - „2V,i—Al6- ( )
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(YIN) Date
15 Type Work ❑ Bldg ❑ MH tP-'1:1-ew 0 Replace 0 Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
Sr4/64 E 1------<17/7/C 7 ,E 51.21=.ez'I /)/si€ ��/11'#6 E
10 Applicant Name Street Address
11 Zip iCity State Phone
( )
*
* Street Address
Lender
Zip City State Phone
( )
Contact Person Phone if different than above
( )
mommonsoor
Additional InformationV '
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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 r
❑ Early Start Release
{ Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential ;j7=
W.1101 College X New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION# ir J -e g37
Conditions/Comments: /��,y� ,�� �� mss• Com_ ��
o�/! '
•
El Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson 0 Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
JWI s
Engineers: ❑ Commercial; Residential; ❑ Flood Plain; I
lIN.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments: /76,-33-S-
D
76, ?3S'❑ Utilities:
I l I I
N.811 Jefferson I
Conditions/Comments:
❑ Other:
l I I
I
❑ Plan Exam
1041
Fire Prey.
Conditions/Comments:
giiii
C
--co Project Representative
Telephone
�a, Agencies Performing Special Inspection:
—I C 1.
. 0
O ._
2 co
i- E 2.
t O
as C
LL
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
4
1-
•;#DORESS: 'L 2_1\NCI PROJECT M:'
General - Yes No N/A
fduwnership Health
❑ A Applicant Increased Lot Coverage?
I3Contractor Addition Bedrooms/
Fixtures?
O Architect Change of Use? _
New Septic?
0' ddress -
BLegal Description Plannin.
124 rcel Number Unplatted Property?
Lot Depth: Width > 3:1?
(Less than 10 acres)
Lot Depth: Width > 4:1? _ _ /
(10 acres plus)
II��Zoning Lot Size Less than Minimum?
8"Site Plan Segregation of Platted
Property?
�
❑ Plat Map Setbacks Less than Required?
ErCermit Description - Frontage less than Required? _
EKlans Not a Permitted Use in Zone? _
O"Completeness Rezone, Conditional Use,
Variance Involved or Required?
❑ Square Footage Commercial Use or Home io//
Occupation? _
O Occupancy Group & Type More than One Residence? 4,o7
0 Departmental Releases Adjacent to a Required
and Conditions - Shoreline?
En.ineerin. /
. New Access/Approach?
Private or Unmaintained
County- Road?
Sega
Underground Tank Over
10,000 Gallons
Commercial Building Over
12,000 Square Feet?
Over 20 Dwelling Units?
Over 40 Parking Spaces?
Agricultural Building Over
20,000 Square Feet?
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical ✓
Use Activity?
REVIEWED BY:! C�l DATE : CSG G�7- S
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