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