1985, 05-14 Permit App 00005404 MHJi
FA
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)
6l
Department Use Only
Res. Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
,/
3 City/Communit
State
Su�Ision/Plat Name
4 Assessor Parcell o.
,V-0641--13_ G��� r,
I Lot Block
{ 15I /
1.1;,
I
* tr i DEPARTMENT USE ONLY
5 Sic Code
Zone Act. ###
Zone P A 14
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
�g (L)S-1
7 Set Back -Front ^e—
x/S
(R)S-2
Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Contractor Firm Name
Street Address
ZIP
City
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 ❑ Bldg
F1 Fire
MHNew
❑ Demo
❑ Add/Alter
I' Replace
-1 Move
El Other
14 Descrige Work
A �7tl
10 Applicant Name
Stree Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
R
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
f his is not a Permit
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
r
❑
Early Start
Release
Release w/cond 1 Hold 2
Environmental Health
W. 1101 College
Room 200
❑ Commercial; ❑ Residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional rructure;
APPLICATION #/i �15(
Conditions/ Comments:
❑
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;
N. 811 Jefferson
❑ drainage ❑ new access/ approach; ❑ fence;
❑ road improvements
Conditions/ Comments:
❑
Utilities:
I
N. 811 Jefferson
—
Conditions/ Comments:
❑
Other:
❑
Plan Exam
Fire Prev.
Conditions/Comments:
Project Representative
Telephone
Agencies Performing Special
Inspection:
C
O
1.
E
2.
O
C
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold