1984, 10-26 Permit App: 00003043 Repair Fire Damage®733
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return thls original and your building plans to the Department of Building and Safety)
1 Owner's Name (last) (first) (m)
Cy ERA
Department ly
Res• Comm
2 Project Address (not Mailing Address) or Road Name Space Zip 1
3 City/Community
� � L1
State
1
LL1
Subdivision/Plat Name
/
i - p o V tam
4 Assessor Parcel No.
^l
A/ r — (C'2 --/
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone Project No.
6 Dwell M
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bads -Front
I (L)S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
(LK O tS �, 51-12u CTt G ;1
Street Address
E.-11 -1-k lc 1cU--
Zip
City
10C.71ti.,Q
State
W
Phone
( ' 4 k11-2-1 t 1
Contact Person License No.
_d 1 i,LS 2E- 40X. \ Z 2S-
Phone If different than above
c 1 <--
->
8 Owner/Ant (if different than 01 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
I SEPA Exempt (YIN)
Date
15 Type Work ❑ Bldg
X Fire
E MH
❑ Demo
E New
❑ Add/ Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
I roue CI 120xc- z G6,t_A6c%
10 Applicant Name
6 A vz..1 rc,LL4 iz
Street Address
E 1-2 z/ 1 -<-, It4
11 Zip
City
SVG,A.L.)e
State
(.V i4
Phone
( ) "7-Z'7/(
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
3t /.c2,ecnc yti/ciS//r/v
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.)
W. 1101 College
Room 200
Conditions/Comments•
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Release
Environmental HealthIIIIIIIIIII
Release
wlcond 1 Hold 2
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lotw/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions /Comments •
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions/Comments•
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
c
0)
c
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