1984, 10-24 Permit App 00002999 CarportBUILDING 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)
//, i< /Z--i ` (.4 4
Department Only
Res.
Comm
2 Project Address (not Mailing Address) a- Road Name Space Zip
i3C7y 4 6 )6• 4 9'9�i"
3 City/Community
5/ f4 ? 7-1 2 q / y
State
C1,1193fy
Subdivision/Plat Name
IV 4/ c7-2, 5 ."' c?' =w 57? 4--
4 Assessor Parcel No. /
,7 5- 4//- d y ^ '
Lot
j
l
Block
I
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
till V C -#-g4
Zone
WerLil -
Project No. ai
��4
6 Dwell #
I
No. of Buildings
2-
Sq. Ft./Acre
Depth
(40
Frontage
7CI
7 Set Back -Front
-/-1TWIC7
(L)S-1
—
(R)S-2 a
1
Rear
--
Census Tract
Module No.
Initials
JUN M
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
_.
Phone if different than above
( 1
Contractor Firm Name
very &::
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 (Y/N)
Other (Y/N)
SEPA Exempt (YIN)
Date
15 Type Work ❑ Bldg
0 Fire
0 MH
0 Demo
0 New
Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
/ ! X 25i ('A !/. Pepe.:./- Ov 4-14v Sr V c+ 7(n .4ev5-2_
10 Applicant Name
t: Le t p -�
Street Address
73h��y 4- i;/4
11 Zip /
77, 7(
City
f49//9,,7--f
State
vu f'4i-
Phone
( ) 7,Zs 2 S 0 7
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.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration /addition
APPLICATION 0
.r
elease
/c. d 1
Hold 2
or
Conditions /Comments•
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; ❑ use/zone.
O CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Com meets•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson ❑ drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments
Utilities:
N. 811 Jefferson
Conditions /Comments•
Other:
Plan
Fire
Exam
'rev.
Conditions/Comments. Z � ice' jc(ec_O
U oak. Fccrt ccN
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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6'
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Sq
37
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