1985, 05-28 Permit App: 00005601 AdditionBUILDING 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)
IJs�Only
rpartment
1 aKe/✓ �,4/KGS s. �/
Comm
2 Project Address (not Mailing Address) or Road Nae Space Zip
E iNarne 76 -
3 City/Comm Wily
State
Subdivision/Plat
AA(rzw3
Name
64u 'Z,wtiCvt
4 Assessor Pa I No. )
CP ^. _ 12 2
Lot
1.--1t
Block
-Z
* ,t +t DEPARTMENT USE ONLY ,t ,t*
5 Sic Code Zone Act. N
Zone A u
/l
Project No. J6 6
S
6 Dwell N
‘
No. of Buildings
1
Sq, Ft./Acre
Depth
i 85
Frontage
1
0
7 Set Back -Front
1 (L)S-1
(R)S-2
1 Rear
Census Tract
I Module No.
Ini ' s ^7y
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( 1
Contractor Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (If different tran N1 above)
1 4C if.
Business Address
9 Zip
City
State I
-.GI- At_12
Phone
)
Review Required
Plan Check /N)
Other (Y/N)
SEPA Exemptl(YIN)
I
Date
15 Type Work =! Bldg
CJ Fire
L MH
0 Demo
❑ New
X Add/Alter
0 Replace
❑ Move
0 Other
14 Describe Wo
10 Applicant Name
144.P.A Pte.
Street Address
1 2 ' J -
11 ip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
(
Contact Person
Phone if different than above
( )
Additional Information
G.-1�' 6A-2.-ir((G4 c5`�r/
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.)
ET
Environmental Health
W. 1101 College
Room 200
Conditions/Comments.
❑ Commercial; Q, Residential
O New Construction; `6� Bldg alteration/addition
❑ Additional s�tr;ctar� r(
APPLICATION 9:Z9
Lkj/ f)(Ai 1/04
Release
Release
w/cond 1
Hold 2
js
I
Planning/Zoning:
N. 721 Jefferson
Conditions/ Comments.
O Commercial;
O Setbacks;
❑ Cert. of Exemption;
0 lot w/d; 0 lot size;
O CU, variance, zone change; shoreline;
❑ Frontage;
0 use/zone;
0 fence;
O Other
Engineers: 0 Commercial;
N. 811 Jefferson 0 drainage
rq road improvements_
Conditions/Comments. 0 r XV \). * 1L )A
O Residential;
O new access/approach;
❑ Flood Plai
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments
El
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 held
UCKYE 4VE-Mit-
PLOT ?LAM
- 2o1
LEGAL DESCR/P770A/: