1984, 08-13 Permit App: 00001741 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)
Owner's Name (last) (first) (m)
Department Use Only
r O
''ILI/� RAY/''t10/ C
e. \� mm
Co
2 Project Address (not Mailing Address) t - Road Came Space Zip
7/C /(A C ke (� P ��� /
3 /Communi y
f
R4 N e,
State
u.) -A-
Subdivision/Plat Name
oP-c.4A20 /Wt Ano "1ZEPC-- XVi
4 r Parcel No.
n 7 c ` `,/ _ , l 2L, v
Y
Lot
Block
,t* * DEPARTMENT USE ONLY ,t* ,t
5 Sic Code
ZZoone Act. #
Zone
T f k -
No.Projec
‘—ie -1-1
1%4-1
6 Dwell #
1
No. of Buildings
Z_
Sq. Ft./Acre
Depth
14-0'
Frontage
1 b
7 Set Back -Front I (L)S-1
(R)S-2
1 Rear
Census Tract
Module No.
I s
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
Gty I
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 (Y/ N)
Other/N)
SEPA Exempt (Y/N)
Date
15 Type Work Bldg
El Fire
❑ MH
❑ Demo
❑/N'ew
Add/Alter
❑ Replace
❑ Move
❑ Other
NDP It(14 Describe Work i ,
o.V r 'ZE�I_be' '� — Flnr(d�~—s(A_n
((
a--oot
0 Applicant Name
ct ���.�� ,i, Oa5 / 4/<
Street Address
t 2/s--- & c k 0� .
11 Zip
11 Zip
9 aril 1
City
A/1IAt
State
//I A
Phone
(505) 9,2V- 33V7
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
so—
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
A"'
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
Conditions/Comments
❑ Commercial; Residential
❑ New Construction; Bldg alteration/addition
❑ Additional structure;
APPLICATION #
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments.
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
O Commercial;
O drainage
O road improvements
O Residential;
O new access/approach;
O Flood Plain;
O fence;
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
a
r
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
Release
Release
w/cond 1
Hold 2
';j ',5 t""
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments.
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
O Commercial;
O drainage
O road improvements
O Residential;
O new access/approach;
O Flood Plain;
O fence;
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
a
r
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