1984, 07-17 Permit App 00001215 Siding, Fascia*
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)
1 Owner's Name
(last)
a II
(first)
(m)
Department Use Only
Rea.
IComm
2 Project Address (not Mailing Address) or Road Name
• �•r44—
5 Sic Code
Space
ir
Zip
i
Zone Act.*
6 Dwell*
State
Lk)
Lot
Block
Zone
No. of Buildings
7 Set Back -Front
(L)S-1
* * * DEPARTMENT USE ONLY * * *
Project No.
Sq. Ft./Acre
Census Tract
Depth
Module No.
Frontage
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Me Um i;m1-ors r�n�rr1 r)rsr Z-16„
City State
s , vKct� u.;
Contact Person License No.
k-�r�.r�l'S 1'Y1�U�cta Im(.-A;11-Yt3- ($LJ tom e,
Zip
ggalD.
Street Address
iJ , 3itoC7 (aarA
Phone �J
( 5q)
Phone if different than above
( )
8 Owner/Agent (If different than *1 above)
9 Zip
12 Review Required
City
Plan Check (Y! N )
Business Address
State
Other (YIN)
Phone
( 1
SEPA Exempt (Y/N)
Date
15 Type Work
❑ Bldg
❑ Flre
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ Replace
❑ Move
14 pescribe Work
10 Applicant Name
Street Address
11 Zip
I City
I State
1 Phone
(
Lender
Stree
t Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
1...11.61A
',
DEPARTMENT APPROVALS
❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
This is not a Permit -
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
Release
Release w/cond 1 i Hold 2
❑
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; E Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/Comments•
Planning/Zoning: ❑ Commercial; Cl Cert. of Exemption; E Frontage;
N. 721 Jefferson E Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments-
❑
Engineers: ❑ Commercial; Cl Residential; ❑ Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments-
Utilities:
N. 811 Jefferson
Conditions/Comments•
❑
Other:
Plan Exam
Fire Prev.
Conditions/Comments:
IInformation LJ
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