1984, 10-12 Permit App 00002816 Double WideBUILDING 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) (5)
rr`//4Sf)00 +D441,,i:co, JI
Department Use Only
ems.
Comm
ess) ress) cr Road Name Space Zip
2 Project Address (not Addr
« E 73 e y 990 i 2
3 City/Community
i�✓c-�^)i r
State
.)4.'
Subdivision/Plat Name A ^
CC3 vb (r.. /k� cr/e-t-.. --zv Grc itioiev -c
4 Assessor Parcel
65r
No.
l OS
Lot
Block
I 9
* * * DEPARTMENT USE ONLY * * *
5 Sic Code)
Zone Act. #
Zone �1 v \
Project No.
6 Dwell #
No. of Buildings
z
Sq. Ft./Acre
Depth +
'245
Frontage
ctc,'
7 Set BacF� nt I (L S--1 (
(R)S-2
!Rear
Census Tract
I Module No.
Initials
UK rn
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
I State
`I
Phone
( )
Contact Person
License No.
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Pl pn (56 ?) 9'2 -2 72
12 Review Required
Plan Check (YIN)
Other (YIN)
I SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
0 Fire
K MH
0 Demo
❑ New
0 Add/Alter
J Replace
0 Move
❑ Other
14 Describe Work
Iz'C'O moan, fl-orn�� 1-4) cA 24 Xs
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( 1
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
APPLICATION ft
❑ Commercial; ❑ Residential
❑ New Construction; 0 Bldg alteration/addition
O Additionalsttucture;
o7z/�
Release
Release
w/cond 1
Hold 2
Conditions/ Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑ use/zone
O CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions / Comments•
Engineers: ❑ Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions /Comments:
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Com men ts•
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
J