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