1984, 08-28 Permit App 00001978 Demo HouseBUILDING 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' Name (las (first) (m) Department Use Only
/ D'2T,Y 't2 e0,e,eT/e.S
Fi38.
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Comm
2 Project Address (not Mailing Address) cr Roaq Name t (, W -e ) I b ( f Zip
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3 �Ci °mmunity
_l `" /4of-GJ�
State,
6--45f4
I
Subdivision/Plat Name
t/A e..€0,&r 4.r /icd0//"/ '
4 Assessor Parcel No.
�/
Lot rvrerin.
o
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. M
Zone
Project No.
� f J
C1
( l
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bade -Front I(L)S-1
(R)S-2
I Rear
Census Tract
I 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
I State
Phone
( 1
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different than 81 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
0 Fire
0 MH
❑ Demo
❑ New
n Add/Alter
0 Replace
0 Move
❑ Other
14 Describe Work .D a v
10 Applicant Name
Street Address
11 Zip
City
State
--Phone ) 9 2,4 - 7/0
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
Fast Track/Special Ins
•
•
r his is not a Permit
Application Type
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Early Start
Release
Release
w/cond 1
Hold 2
•
0
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ 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; El lot w/d; ❑lot size; ❑use/zone;
1
I
I
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments:
Engineers: N. 811 Jefferson 0 Commercial; 0 Residential; 0 Flood Plain;
0 drainage ❑ new access/approach; 0 fence;
i
0 road improvements
Conditions /Comments
Utilities:
N. 811 Jefferson
Conditions / Comments-
•
Other:
Plan Exam
Fire Prev.
•
Conditions/Comments.
1 Information ❑
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
ate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold