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1985, 07-09 Permit App: 00006289 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' ame (last) s(first) (m) Deportment Use Only tS j f� y Res. Comm 2 Project Address not Mailing Addr ss) a Road • e Space Zip 3 City/Com ty J #4),..c._ State G(}A. Subdivision/Plat Name PI jioesl Ft / rz-0-N ifri 4 Assessor rcel No. 6 5'4 I ^ 1 f 1 `/ LotBlock 1 5 I (I * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act. # Zone �� �v Project No. 6 Dwell # No. of Buildings Sq. Ft./Acre Depth / 135 Frontage Gi 0 I 7 Set Back-Front(L)S-1 3 2 ` �- X/ t (R)S-2 Rear Census Tract Module No. Initials \l U rJ on . 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone If different than above ( ) Contractor F ame/' /tom 5'/ L Z/j � Street Addrese ! 7 % /•OJiC.r[ Zip Cl 2.4.)7 CityState S z7 /6.1,2.,s.I at License Phone (5`-/) `CRY -.?mss 8 z_ Contact Person No. S fDK45Z^ /7v c i4., Phone if different than above ( ) 5..—.2-- 8 Owner/Agen i different han #1 above) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check (YIN) Other (Y/N) SEPA Exempt (Y/N) Date 15 Type Work ❑ Bldg ❑ Fire ❑ MH ❑ Demo ❑ New %. Add/Alter ❑ Replace ❑ Move ❑ Other 14 Describe Work Silk ©M 1 S 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 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.) Environmental Health W. 1101 College Room 200 ❑ Commercial; ❑ N w Construction; ditional structure; APPLICATION # ❑B,esidential ceoldg alterati addition 3-659 '2 - Release Release w/cond 1 Hold 2 ir Conditions/ Comments• Conditions/Comments• Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage; N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; ❑ CU, variance, zone change; shoreline; ❑ fence; ❑ Other Conditions /Comments. Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence; O road improvements Conditions/Comments• Utilities: N. 811 Jefferson Conditions/Comments• Other: Plan Exam Fire Prev. Conditions/Comments• Project Representative Telephone Agencies Performing Special Inspection: 1 3 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold W N