1985, 10-02 Permit App 00007802 Residence, GarageBUILDING 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)
DapartmenttSseOnly
2 (0/1 7)Se-/-"/ ();:,A2 5 /
I Res.
Comm
2 Project ress (n t Mailing Address) Road Name Space Zip
3 City/Community
Sc) ,74 4) E
State % 1
S'ision/Plat Name"../ /
U pmJDEa20 S 609L/Q! ��PLC
4 Assessor Parcel No.
Pri\J •, Cr/, — /e I 1
Lot
/3
Block
I J
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
I Zone Act. #
Zone
Project No. ./7
30C/
6 Dwell #
1
No. of Buildings
1
Sq. Ft./Acre
Depth
/ 7._
Frontage
ISO _Q7
7 Set Back --Front t
(L
(R)S-2 j Rear
Census Tract
Module No.
Initials
L rI
16 Architect Firm Name
574 Al ..6
Street Addr s
Zip
99�o
City
SPo f,,0 /
State
L1----74
Phone
(50?) e/y7_ 7.7 ? 7
Contact Person 0
Phone if different than above
Contractor Firm Name
Street Address
Zip
City
[State
Phone
( )
Contact Person
License No.
2,0,un2c1 1�a 4
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
S4
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other (Y/N)
1SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
0 Fire
❑ MH
0 Demo
New
0 Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
nif - f oil
Oia =
j3001
(Ili
AIL ;71
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Application Type
(Standard unless
otherwise indicated)
Fast Track
f Early Start
Environmental Health
W. 1101 College
Room 200
Conditions /Comments
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑ Commercial; ❑ Residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION # D —/I-2--
Release
Release
wlcond 1
Hold 2
4.
.I
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments'
Engineers:
N. 811 Jefferson
Conditions/Comments•
❑ Commercial;
❑ drainage
❑ road improvements
O Residential;
❑ new access/approach;
❑ Flood Plain;
O fence;
Utilities:
N. 811 Jefferson
Conditions/Comments-
0
Other:
b7L
m
U
N
o.
c
O
Es as
O
co
Plan Exam
Fire Prev.
Conditions/Comments-
Q104- (eNlr
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
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