1985, 02-27 Permit App 00004297 Relocate Residence on BasementBUILDING 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) Use Only
/
Y 0! Cal 9 L rl 0
'Department
Ras.
Comm
2 Project Address (not Mailing Address��af Road Name Space Zip
5, Co(F id -I, fokD
3 City/Community
J n /\ cL ri C"_ _
State
(�-" I�
Subdivision/Plat Name
4 r Parcel No.
/V /
T
Tt� _ ! -3 t T V.
Lot
Block
I
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
A7
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Backront (L S-1 ,
(R)S-2
'Rear
Census Tract
Module No.
Initials
Jo0 C •
r 16 Architect Firm Name
I Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
-Sr`.c ✓r► e"- a 5 6- .60 ✓
Street
Address
. /U .J G x o2.>'.-
Zip
City
S fd/Ca_n .
State
Wc_ -
/
Phone
( ) G,. 26 —07�—
Contact Person
(..) b ,' SCSCii
ii
License No.
l 3 - /' L
I - c2`73,L-�
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 (YIN)
Other (YIN)
1
t SEPA
Exempt
(YIN)
Date
15 Type Work ,
0
Bldg
Fire
❑ MH
0 Demo
❑ New
❑ Add/Alter
❑ Replace
Move
0 Other
14 Describe Work
R AG
W; 1 P c.,-
601 ePr mm
T
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
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N'b U. s (S PS S T (4 Lo (, .I 1" 5.530 Pf n)S SPF("„ I Nsp _ = 57) ,
DEPARTMENT APPROVALS
•
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
•
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration /addition
Room 200 ❑ Additional strriucture;
7 -1s-�'A�
f� . p j, C f
( `t`1
APPLICATION # 6- -oe
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Conditions/Comments. /ice -mil
.
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W.,„...z,—y-ely,`
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ID Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
'41
i
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
Engineers: ❑ Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
❑ road improvements e__-------/
Cond' ions/ omments•
•
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
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