1984, 06-25 Permit App 00000820 Covered Decka
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)
prll�a 7? i yr r v
2 oject Address (not Mailing Address) a Road Name
(first)
Department Use Only
nes.
Zip
Comm
3 City,/Community` £
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State�
U(�
SubdivisionahPlat Name s' '
Vera
P era
4 r Parcel No.i
2`J gel Cis , d
Lot
Block
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• < DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. IS
Zone (q /q� /q�
Project No.
6 Dwell #
/
No. of Buildings
°ram
Sq. Ft./Acre
1 - 10 ' acres
Depth }
&P''CO
Frontage
1 (0 0
7 Set Back -Front _
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(L)S-1
(R)S-2 Rear
census Tract I Module No.
Initials
c al
Street Address
Zip
City
State
Phone
)
Contact Person
Contractor Firm Name
Phone if different than above
)
Street Address
Zip
City
State
Phone
)
Contact Person
8 Owner/Agent (it different than #1 above)
License No.
Phone If different than above
)
Business Address
9 Zip
12 Review Required
15 Type Work
City
Plan Check (Y/N)
❑ Bldg
❑ Fire
❑ MH
❑ Demo
State
Phone
5?)9 £ 2$ 32 EN
Other (Y/ N) ' SEPA Exempt (Y/ N)
B- New
❑ Add/Alter
❑ Replace
❑ Move
Date
tr—Other
14 Describe Work
3— Side 0
10 Applicant Name
err t&cl vei'ed (kJ& /C' )7c
Street Address
11 Zip
Lender
City
State
Phone
)
Street Address
Zip
City
State
Phone
Contact Person
Additional Information
Phone if different than above
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 ❑ Commercial;
W. 1101 College ❑ New Construction;
Room 200 ❑ Additional structure;
Conditions/ Comments.
❑ Residential
❑ Bldg alteration/addition
APPLICATION F
Release
Release
w/cond 1
Hold 2
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
Engineers: ❑ Commercial; ❑ Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; ❑ fence;
O road improvements
Conditions/Comments
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
Plan Exam
Fire Prev.
Conditions/ Comments-
0
0
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0 ._
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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
to
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