1984, 06-29 Permit App: 00000978 AdditionBUILDING 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) Only
rpartment
1C !2 O t>S � Q r�,r�is clie.
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
//g IV- A302•4'V r RD Y. 21ft.
3 City/Community
CO `r„ii 4/,4',/ 9-7'
State
(kJ 4.
Subdivision/ Plat Name
---1 C 2S Cmc T
4 Assessor Parcel No.
1
4S4 - _ /-)
�J
Lot
Block
10
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone, �
y
Project No. /^,t ./� f1
I J/ 0
6 Dwell ft
No. of Buildings
t
Sq. Ft./Acre
L2'
Depth
tf
Frontage
} Z -S'
7 Set Back -Front (L)S-1
(R)S-2
1 Rear
Census Tract
I Module No.
Initials
L.
16 Architect Firm Name
Street Address V
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
/3Ef r W /f'Y t:G.�S K /C 7/e #
Street Address
deo w /i / 13Gx.rj' ,,S- 406A. ,C,K/c
Zip
9 9' /4/ r
City
:LOON LAk .r'
State
Ade 45C/`•
Phone
(6-6 9 ) J._ 33 - ..10 )0
Contact Person
/30,6 :17-i,e, /y. - g/; 7
License No.
b F £r .U -k, 1 D o Ur
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)
Aire
Other (YI )
SEPA Exem�
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Replace ❑ Other
D Move
.. A d/Alter
a
14 Describe. ork 14 -pg -T-10 )G
-r. / SI-" s+ & Go# s (3 ',LT Po
f 4 rq 1 /1-4 /t''/LOA 01
7- /4Y 1-b 6z,> ;.A1 AILS 70 ,fir
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
__
I• •
f
DEPARTMENT APPROVALS
]
]
Application Type
(Standard unless
otherwise indicated)
Fast Track
arly Start
I I IIJ IJ 1101. a rwi h il l
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
U.
Environmental Health ❑ Commercial; , Residential
W. 1101 College ❑ New Construction; dg alteration/addition
/ , I 1
1,
Room 200 Cl Additional structure; r
APPLICATION # [Q 0o0 e/.c -
Conditions/ Comments'
❑
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
lot ❑ lot size; 0 use/zone;
N. 721 Jefferson ❑ Setbacks; ❑ w/d;
❑ CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
0 road improvements
Conditions/Comments.
❑
Utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
❑
Plan Exam
Fire Prev.
Conditions /Comments•
I Information DI
Telephone
Project Representative
Agencies Performing Special Inspection:
1.
2.
3.
l
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold
1
p reposed
C!okC
t )
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