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1984, 05-29 Permit App: 00000397 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) i (first)( �Dspartmertt/Only /re���__: ' e //S ! r C[IS� `- Fts. Comm ( 2 Project Addreee (Trot ' .. • • aes) or Name Space Zi 97; 3 Clty/Co unity r ©/ �-or�K Stt tte 5 ��(! G f - Subdivision/ Plat Name 4 Pwcel No. / a'1 542 '' 1 c Lot Block * * * DEPARTMENT USE ONLY * * 5 Sic Code Zone Act. 0 '' Zone Project No. 22611 6 c e$IN No. of Buildings Sq. Ft./Acre Depth 40 Frontage % 7 Set Back -Front (L (R)S-2 Raar 1 (kraus Tract Module No. F t-2)------- L 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Contractor Firm Name Street Address Zip City State Phone ( Contact Person License No. Phone If different than above ( ) 8 Owner/Agent (if different than ll above) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check (Y/N) �i 7❑ SEPA Exempt CO NI.... Other NN)) Date I yew 15 Type Work Bldg 0 Fire MH C Demo 0 Add/Alter 0 Replace E. Move 0 Other 14 Describe �Work 400 Cr c• 'v -cc, ^+e % tic:, ti+ Glom 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 not a Permit (Indicated approvals required in either "release" or "release with conditions" space prior to permit issuance.) Environmental Health W. 1101 College Room 200 Conditions / Comments - ❑ Commercial; d idential ❑ New Construction; Idg alteration/addition ❑ Additional structure; APPLICATION # Release Release w/cond 1 Hold 2 'r�77 e-9/. Planning/Zoning: N. 721 Jefferson Conditions/ Comments • ❑ Commercial; 0 Cert. of Exemption; 0 Frontage; O Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone; O CU, variance, zone change; shoreline; 0 fence; O Other Engineers: ❑ Commercial; 0 Residential; N. 811 Jefferson 0 drainage 0 new access/approach; ❑ road improvements Conditions/Comments• O Flood Plain; O fence; Utilities: N. 811 Jefferson Conditions/Comments Other: 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 6