1984, 06-28 Permit App: 00000928 DeckBUILDING 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
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/E/y
�!'f(1.04 7l %15
Ras.
Comm
2 Project Address (not MailingAddress) or Road Name Space Zip
-L41;7.2-gidteii4�` /9.-e&„// It ry��q�� 9itaz/ .
3 City/Community
(.13'ee-i,atre/ae.s
State
1U1
Subdivision/Plat Name
6-0r iii D
4 Assessor Parcel No.
20552- - o233
Lot
Block
. f ♦ DEPARTMENT USE ONLY
5 Sic Cade
Zone Act.*
Zone ! , `s” 'vl
1 6
U
Project No. 1 7/6
6 Dwell I
No. of Buildings
3
Sq. Ft./Acre
Depth 1
f3)o
Frontage
1561
7 Set Back -Front
��I�
(L)S-1
(R)S-2 Rear
census Tract
Module No.
Initials
Jud rn
16 Architect Firm Name I Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
( 1
Contractor Firm Name
Street Address
Zip
City
Slate
Phone
1 )
Contact Person
License No.
Phone If different than above
1 )
8 Owner/Agent (if different than (1 above)
Business Address
9 Zip
City
State
Phone _
( )
12 Review Required
Plan Check (Y/N)
Other (YIN)
SEPA Exempt (YIN)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
❑ Demo
New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
GaSP i_. --ii
/ ,76 � ,����� v Z — �a X ,:z9 / /42&VA/ .a.-eA/-'� caX' ) /J/
c/42
10 Applicant Name /
Street Address �i -
i1 Zip L
99D/�
City
o`i ,a77-"ls
State
/�//,19
•' Phone
( 5277 :-.727-:.--1- ce�.ja
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Additional Information �..,(
55-7
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m
0
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V
N
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u.
DEPARTMENT APPROVALS
•
❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
i nis is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
'Hold 2
Er
Environmental Health 0 Commercial; 0 tial
W. 1101 College ❑ New Construction; 0 Bldg alteration/addition
Room 200 0 Addit�uctu
al strre;
Cp�
I�O
c 3
APPLICATION 3 `(C' 3
Conditions/Comments
❑'
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
❑
Engineers: 0 Commercial; 0 Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage 0 new access/approach; ❑ fence;
❑ road improvements
Conditions /Comments'
❑
Utilities:
N. 811 Jefferson
Conditions /Comments•
❑
Other:
•
Plan Exam
Fire Prey.
Conditions/Comments.
Project Representative Telephone
0
Agencies Performing Special Inspection:
1
to
E
`o
2
c
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
4 ;
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