1985, 12-13 Permit App 00009148 Residence*
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)
•
t TC..C., y ti f� f- w • 1 I 1 •— `— .--
(last) (first) (m) Department l e Only
1 Owner's Name
/
Ill (0 I ('� L l il f( A-- I
✓
RBs. ,-"'
Comm
2 Project Address (not Mailing Address) or R Name Space Zip
O Fe S ! EDG) j q q 20 (o
fJ ,,lL+
,
3 City/Community
State
Subdivl !Plat Name
4 Assessor Parcel No.
f t f q- -� 7/ '-f-
Lot
` !
Block
J
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
15(.60
Depth
Frontage
��U
7 Set Back -Front
(L)S-1
(R)S-2
Rear
I
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
Iti1(Ai r
o. 3
Street Address
3 I o;4, Ai i)n Y COOd
Zip
q4 212
City
S'
4a. itA___
State
u0A
Phone
(5)1) qz 8—f 86
Contact
7, rw'
Iii c.Yi,,u4
License No.
M c 0A Yt3(346in
e
Phone If different than above
( _
8 Owner/Agent (if different
than N1 above)
Business
Address
9 Zip
City
State
Phone
( 1
12 Review Required
Plan
Check (Y/N)
Other (YIN)
1 SEPA Exempt
(Y/N)
Date
15 Type Work ❑
❑
Bldg
Fire
7 MH
LE Demo
-' New
- Add! Alter
a Replace
Move
Other
14 Describe Work,
10 Applicant Name
Street
Address
11 Zip
City
State
r Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( 1
Additional Information
\TOL a_+irm — 16 J3toZ`z'
PIA mr 4- E 0 - 4 6°% E s= ; 60 -
DEPARTMENT APPROVALS
Fast Track/Special In
•
•
Application Type
This 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.)
Early Start
r
Release
Release w/cond 1 Hold 2
Environmental Health 0 Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions /Comments:
•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
1
0 CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions /Comments •
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811Jefferson 0 drainage ❑ new access/approach; 0 fence;
0 road Improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/ Comments •
Other:
Plan Exam
Fire Prev.
•
Conditions/Comments.
Information ❑
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