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1984, 10-08 Permit App: 00002705 DemoBUILDING 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) C Y j AL. -1: -0( ry 6 v-eg 0 Department Use Only Res. Li Comm 2 Project Address (not Mailing Address) or Road Name Space Zip ci,a-- N . 12x'-3 41 A IN) ?CXa 3 City/Community State Subdivision/Plat Name .,.A ---Te SPitSi Kik(.► C.- 1 PA o(7 4 Assessor Parcel No. 1 s`5 -22I - ) t7-.41 Lot C Block * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act. # Zone t'S Project No. z76)� 6 Dwell # t No. of Buildings Sq. Ft./Acre Depth Frontage 7 Set Back -Front 1 (L)S-1 (R)S-2 I Rear Census Tract Module No. Initi Q 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Contractor Firm Name Street Address Zip City I State Phone ( ) Contact Person License No. 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 (Y/N) Other (Y/N) ate SEPA Exempt (Y/N) X() 15 Type Work "❑ Bldg ❑ Fire ❑ H V Demo ❑ New ❑ Add/Alter ❑ Replace ❑ Move her 14 Describe Work AP i S f-1 TL— t�stve- { , N or- -2b 10 Applicant Name Street Address x,03 N . "ezzscot,..,,-- i,...., 11 Zip ctGt 2. City State Phone (6 -e --JT et a41- -67--sTh Lender Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Information DEPARTMENT APPROVALS • ❑ ED Application Type (Standard unless otherwise indicated) Fast Track Early Start I iii I IJU[ d rerrlilt (Indicated approvals required in either "release" or "release with conditions" space to issuance.) prior permit Release Release w/cond 1 Hold 2 Ej Environmental Health [1 Commercial; 0 Residential W. 1101 College 0 New Construction; 0 Bldg alteration/addition Room 200 ❑ Additional structure; APPLICATION # Conditions/Comments: Il Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage; 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone; N. 0 CU, variance, zone change; shoreline; 0 fence; 0 Other Conditions/Comments: n Engineers: ❑ Commercial; 0 Residential; 0 Flood Plain; N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence; 0 road improvements Conditions/Comments: 0 Utilities: N. 811 Jefferson Conditions/ Comments LI Other: Plan Exam Fire Prev. Conditions/ Comments' Project Representative Telephone Information 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