1985, 08-02 Permit App 00006315 Residence, GarageBUILDING PERMIT APPLICATION WORKSHEET
2)
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) Usip.6niy
'Department
r nn
�INIGH. c rQ[Ov1
-
Comm
2 Project Address (not MailingAddress)or Road Name n Space Zip
5 ,o 2JS Dt-75- -wood Cz-
3 City/Community
5/00)(g..1..Q,` .-_
State
(-Jr.-
Supctivision/Plat Name n (�
C`''OI"cL�tr-o 3 g- �--( �t:LCX . Qlit:44:1-
4 Assessor Parcel No.
32 S 'T./ — /9// -
Lot
1
Block
* * * DEPARTMENT USE ONLY ,t
5 Sic Code
Zone Act. #
Zone
'SF 12-
Project No. ! /
(p3i i2
6 Dwell 0
i
No. of Buildings
i
Sq. Ft./Acre
Depth
14-& •
Frontage
, (-71
7 Set Back -Front
`moo`
(L S-1 _ t
l�
(R)S-2
Rear _ ,
j
Census Tract
Module No.
(
Ini ' s
`'"
' 16 Architect Firm Name
Street Address
Zip
VVV
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Gordlvt-, T IMc- /4 meS
Street Address
N 5rv6) /Th.//a. t
Zip
?' 20.6
City
Spb 1.- w�
State
c,� _
Phone
( ) I215 — 7043
Contact Person
G60-A� TInG4
L No.
fiiNtCft('
2Gj PF 2z3�1
Phone If different than above
( )icense
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
r
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
•
SEPA
Exempt
(YIN)
Date
15 Type Work ❑ Bldg
Alto 5t4, /, Fowl. pi,4) , ❑ Fire
❑ MH
❑ Demo
X New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work / D
r'r. �{ 4R `G •[
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
( F (S l
06 - [s1(
‘frYt = 1( v
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.)
LyJ
Environmental Health
W. 1101 College
Room 200
Conditions/Comments
D Commercial; tiv residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION # C 0 7-3
Release
Release
w/cond 1
Hold 2
v
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
O Other
Conditions/Comments-
Engineers: ❑ Commercial; ❑ sidential;
N. 811 Jefferson ❑ drainage new access/approach;
❑ road improvements
Conditions/Comments
/Y✓/r'- 37r
D Flood Plain
0 fence;
Utilities:
N. 811 Jefferson
Conditions/Com ments•
Other:
Plan Exam
Fire Prev.
Condi tlons /Com men is•
5
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.../° BSc.
zit<)44" •
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45"