1984, 07-31 Permit App 00001505 Patio•
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)
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1 Owner's Name (II st)) �n %� W (first) (m)
Ck%1`� YC ere,p-n
DepartmentUse Only
Res.
Comm
`
2 Project Address (not Mailing Address) orRoad Name Space Zip i�
6r---to LL / / / /'5 U ��( -/T/J� - r9LV 4 6
' 3 CityL ommunity
0�
State
� /,�
Subdivision/Plat Na
r' C 'e- C;�2 --C: � (A) L T'-
4 r I No. G — ' / 1 --� /�{
Lot
Block
1 �3 2
. . + DEPARTMENT USE ONLY * * it
r n � 4-
A / a v/f_,
5 Sic
Zone Act.
Zone
Project No.
I6t.7
6 Dwell M
No. of Buildi if
Sq. Ft./Acre
Depth
Frontage
7 Seont _�`
1(L)S1
(R)5-2
Rea
(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
�6ic�
City
e
State
to
Phone
( ) 9 6---/s/ r(-)
12 Review Required
Plan
Chec (Y/N)
Other (Y/N)
I SEPA Exempt
(Y/N)
Date
15 Type Work C]
0
Bldg
Fire
0 MH
❑ Demo
0 New
C Add/Alter
(-', Replace
0 Move
0 Other
14 Describe Work
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ro('✓to
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E►�,
10 Applicant Name
/17
Street
Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
1 )
Contact Person
Phone if different than above
( )
Additional Information
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.)
Environmental Health
W. 1101 College
Room 200
O Commercial;
0 New Construction;
O Additional structure;
❑ Residential
O Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
ii
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;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments'
Engineers: 0 Commercial; 0 Residential;
N.811 Jefferson 0 drainage 0 new access/approach;
0 road improvements
Conditions/Comments •
O Flood Plain;
❑ fence;
CI
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions /Comments •
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
/ 6 ' 3 it ' / 7 �e
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