1984, 08-07 Permit App 00001644 GarageBUILDING 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)
Department Use Only
0c.'"D. �- �� Z/ z /=� i✓ :fig-
Ras. Comm
2 Project Address (not Mailing Address) a Road Name Space Zip
Y
3 City/Community
,-Sie9Dkk w
State
.
Subdivision/Plat Name
LI e e Sow
S iN 2 1 i(
4 Assessor Parcel No. r..
j S 1- 7--— v -.)
Lot
I Z
Block
7
* * *
DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone /}' �` /�s 1 f o
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth )
( ' ✓
Frontage
_
7 Ser�+
(L)S-1
(R)S-2Rear
l
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
[State
Phone
( )
Contact Person
License No.
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)
r SEPA
Exempt
(Y/N)
Date
15 Type Work Q---Bldg
0
GF.2Q/',7
Fire
❑ MH
0 Demo
'9'
New
ElAdd/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work
i
.L/ X /Y /4/0
c :,
10 Applicant Name
a d, r2- / /
- /
— -:/'C ` /' Z,`-
.We-
Street
i:"
Address (---
— ad/ , rS� _
11 Zip
G7'T 4''
City
G�;/�;*Qr C�
State /
,t,),c'Sf L (SG?)
Phone
4/- G7e/
/
Lender
Street Address
Zip
City
State
Phone
( )
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.)
E
Environmental Health
W. 1101 College
Room 200
Conditions /Comments
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION 11
Release
Release
w/cond 1
Hold 2
❑
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone•
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Com ments•
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions /Comments'
Utilities:
N. 811 Jefferson
Conditions/Com ments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments
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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G—a j -size
7 5 / L/ i d
ProPe-C:j' L I A/t,