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1984, 08-14 Permit App: 00001760 MH* BUILDING 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) l/k% N 1 i—Q 1 itn K Department Usk Only s. V Comm 2 Project A& jrg lnot MailiingAddress) or Road Name Space Zip `i)6 /V` 13010rv),‘)/I %g'31/a 3 City/Community AA) y State r..J Subdivision/Plat Name E. - oe..p. rvE tpo 4 Assessor Parcel No. '53 l, Lot i Z Block 3 * * * DEPARTMENT USE ONLY 5 Sic Code Zone Act. N Zone ^ Project No. 6 Dwell # t No. of Buildings /` Sq. Ft./Acre Depth , )2 U Frontage 4-01 7 Set Back -Front / (L)S-1 �_.f '1� ( 04(.1 _ (R)S-2 Rear - Census Tract Module No. Iryii is �� \J 16 Architect Firm Name Street Addres lbl N. en"? niA-v Zip 9 9,)> A City :51006941P- State /i'U,9. Phone 5 ,) cc? ,a 37 Contact Person c{ �` J '} Phone if different than above Contractor Firm Name / iii Street Address Zip City 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 (YIN) / Other (YIN) SEPA Exempt (Y/N) Date 15 Type Work fl Bldg ❑ Fire Pr' MH ❑ Demo ❑ New ❑ Add/Alter ❑ Replace ❑ Move ❑ Other 14 Describe Work -��l 1 .1 N4 LE w i Ae- *4 . N ' c-Eim eniT (4r) 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 LI Application Type (Standard unless otherwise indicated) Fast Track Early Start DEPARTMENT APPROVALS This is= a Permit (Indicated approvals required in either "release" or "release with conditions" space prior to permit Issuance.) Environmental Health W. 1101 College Room 200 O Commercial; O New Construction; • Additional structure; -11N Residential 0 Bldg alteration/addition APPLICATION # Release —7---------------_ Release w/cond 1 Hold 2 Elie— 4 MN Conditions/ Comments LI Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage; N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone; O CU, variance, zone change; shoreline; 0 fence; O Other Conditions/Comments: Engineers: 0 Commercial; 0 Residential; 0 Flood Plain; N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence; O road improvements Conditions/Comments. El Utilities: N. 811 Jefferson Conditions/Comments- Other: Information 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