1986, 05-22 Permit App: 00011170 ResidenceA
BUILDING PERMIT APPLICATION WORKSHEET 431
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/ (las (first) (m) Department my
w0IFI. ✓ 0 Res. Comm
2 Project Address (not MailingName / Space Zip
ggpAddress)
,or/Road
3 City/Community State Subdivision/ Plat Name
QSi 25oResr e VggS 21,d
4 r Parcel No., Lot Block
DEPARTMENT USE ONLY
l! O
Zone Act. #
Zone �.
=Pr.j-tN.
d
FDNel1�
No. of Buildings
Sq. Ft./Acre Depth
Frontagei
�
C,v.
nt (L)S_1 f
(R)S-2 c
Rear
Census Tract
Module No.
Initials`` SS
C
N Yip -
16 Architect Firm Name
Street Address
Zip
City
S � D k c�.A�
State
L.J .
Phone 7 i 0-6
( ) 2 to
Contact
Contact Person
Phone if different than above
Contractor Firm Name
Street Address
r ,J(/ (2,) .
�.
Zip
City
State
Phone p p
Cont Person /
License No.
Phone if different than above
8 Owner/Agent (if different than #1 above) &I
Business Address
g Zip
City
State
Phone
12 Review Required
Plan Check (YIN)
Other (YIN) SEPA
Exempt (YIN)
Date
15 Type WorkI. Bldg
ElMH
ElNew
ElReplace
ElOther
❑ Fire
❑ Demo
❑ Add/Alter
❑ Move
14 Describe Work
ce
10 Applicant Name
Street Address
11 Zip
City
State
Phone
1
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
s� U
Application Type
(Standard unless
otherwise indicated)
❑ Fast Track
❑ Early Start
U
a
FEW
0
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 # �192�
Conditions / Com
ments:I��L
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; `3
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements ��a- /l�
Conditions/ Comments:
Utilities:
N. 811 Jefferson
Conditions/ Comments:
Other:
❑ Plan Exam
Fire Prev.
Conditions/ Comments:
ProJect Representative
Agencies Performing Special Inspection:
2.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Telephone
Release
Release w/cond 1
Hold 2
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; `3
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements ��a- /l�
Conditions/ Comments:
Utilities:
N. 811 Jefferson
Conditions/ Comments:
Other:
❑ Plan Exam
Fire Prev.
Conditions/ Comments:
ProJect Representative
Agencies Performing Special Inspection:
2.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Telephone
v
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