1985, 06-21 Permit App: 00006046 Mobile Homev
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 Namelast) (m) Department Use Only G_
,�, ` `,, —((first)
/! !'Cit% PA I \ `✓'E;rv.,/ 14 Res.
f
Comm ✓
2 Project Addr (not Mailing Address) or Road Name Space Zip
-./9t,(', A/e 99 ini.0
City/Community ,���^+
'e"e it /�-S
State
1/.C,/ X
Subdivision/ lat Name
, t....L44.e...ce44....<_.
4 Assessor Parcel No. ,---/
��� 0� J�"
Lot
Black
/
* * * DEPARTMENT USE ONLY
5 Sic Cade
Zone Act. #
C6--2g-c )
Zone
Project No.
oc ¢ (:,
6 Dwell #
No. of Buildings
. /
Sq. Ft./Acre
Depth
/ l 8
Frontage
f-75
7 Set Back -pint
`I/
l (L)S-1
(R)S-2
/6Rea`
Census Tract
Module No.
Initials_
alp
/
16 Architect Firm N//'' -- __ --
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City
I State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work 0 Bldg
0 Fire
a22MH
0 Demo
P•'/New
0 Add/Alter
I ' Replace
0 Move
0 Other
14 Describe Work
0Ct e i E- tvi O> Aw )31 1_6 /-10,44E }l2- ; (C'AFETAkC%'
10 ii, plicant Name i Street Address
/3//D 7TILd
r Zip
Ain)/
C�c
J
State
GGA #
Phone
6' ) l �i 6907
Lender
-----1,--"'e5--2tiR—___ -
Street Address
Zip
City
State
Phone
l 1
Contact Person
Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
fl
•
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
1 1115 IS nut d ret II II L
(Indicated approvals required in either "release" or "release with conditions"
issuance.)
space prior to permit
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; E Bldg alteration/addition ,/4;,
;
4- -‘ 5
Room 200 ❑ Additional structure
APPLICATION # kJ - G5 5" �4/
(-6 —e-�
Conditions/Comments:
ei
Planning/Zoning: ❑ Commercial; E Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot wld; ❑ lot size; ❑ use/zone;
4 if 13
V'
❑ CU, variance, zone change; shoreline; ❑ fence;
0 Other
Conditions/Comments:
GXFOE- C t s —e -v0 /AU ,FFs-r Pt'7V C (5.-
XEngineers: 0 Commercial; 0 Residential; 0 Flood Plain;
gt
6�'"Z t
i
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
0 road improvements
Conditions/Comments-
•
Utilities:
N. 811 Jefferson
Conditions/Comments:
•
Other:
Plan Exam
Fire Prey.
Conditions / Com ments• st4,e0�.c-r -no PLMJNPAIt DEPARThifiktr AVP/taUlkt_. DouBLE. UM- 1 .S1D£NCE CCAS
(NO CoB'11i7fE.i?-.C(AL OSI GE Lair ) DI..00/(.1pDf7 /ES CO,i SjN ski rt .S7'Ie-Cg IP mcgu �HarkS Ii 01.(LlMYlrt.l'1-r
o't. mr;tslul✓Accu#.f.t2.s 5-fCG)lct}rlo14s. WA<. - Z - MO
Information ❑I
Project Representative Telephone
Agencies Performing Special Inspection:
1.
2.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
.1
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