1985, 02-07 Permit App: 00004113 RemodelBUILDING 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) r Department Use Only
7
1 C.% j '1) d f Fes. Comm
2 Project Address (not Mailing Address) a. Road Name Space Zip
3 CltylCommunity
ac
State
�'/�
Subdivision/ Plat Name
DPP F(2 -DSS 41 5XG S
4 Assessor Parcel No.
4Z ' 01 1 1
1 / 547-
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. M
Zone
J
itv
Project No. 1 i
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
(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
Street Address
Zip
City
State
Phone
Contact Person
Com.-L� --c:
License No.
71/Z ,7-4. �/ <--,;01-)
Phone If different than above
( ) 2�� ,7� s
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other (YIN) 1SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ AddlAlter
Replace
❑ Move
❑ Other
14 Describe Work ----, f� �L ,—F� /
l')A-) li !'`,[�,1-1 l trc/Lt1'C / /\F is/i� CF' / e 74, L -t` . -L e/4 l'i GC c
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
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota 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
Release
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments•
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative Telephone
Agencies Performing Special Inspection:
1
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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