1984, 12-06 Permit App 00003651 MH- g Gf -3 3 -f
1.
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) Department Use Only
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2LProjeect Address(not Mailing Address) a' Road NameSpace Zip
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3 City/Community
S R /.,-
State
Subdivision/Pl a
SP `{ 77' �l /
4 A r Parcel No. 05' q3 (,
T DIV�
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Lot
Block
( 7
,t ,F * DEPARTMENT USE ONLY * * *
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Cro r
5 Sic Code
Zone Act. #
Zone (
Project No.
6 Dwell #
P
No. of Buildings /
J
Sq. Ft./Acre
Depth
1( .i
Frontage
6�
7 Set Bads -Fr I (L)S-1
(R)S-2
I Rear
Census Tract
I Module No.
t Initialls
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
12o a
City
State
Phone
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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 (YIN)
I SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
0 Fire
Er-MH
❑ Demo
New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe - A of / // 4 e 5)(45 (<13��z,P ^I)
v
/VrStreet
10 Applicant NName
Address
11 Zip
City
State
Phone
( )
Lender
Street Address
I
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions/Comments-
❑ Commercial;
❑ New Construction;
❑ Additional structure;
APPLICATION it/4 D % /� 21
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
L'J
Planning/Zoning: 0 Commercial; ❑ Cert. of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions /Comments
Engineers: 0 Commercial; 0 Residential; ❑ Flood Plain;
N.811 Jefferson 0 drainage Er new access/approach; ❑ fence;
❑ road improvements
Conditions /Comments'
Eim' di/
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
El
Plan Exam
Fire Prev.
Conditions/Comments'
Agencies Performing Special Inspection:
1
Project Representative Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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