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1985, 08-07 Permit App: 00006571 ResidenceBUILDING 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) partmentnl Y Ct. it' 111,{3` J j #1 ..1lZf 2 Fs. .7 Comm I 2 Project Address (not Mailing Address) or Road Name Space Zip . / 'L / = ©.; 1� / r Ai /�.v'''. (f QeJ'% 3 City/Community f V pA O rf- State Subdivision/Plat Name _ /A4 8-S 1 A 4s S .,'p '_ 'e oN J 4 Assessor ParcelfNo. -_ 5 r7 - O 3 `I 7 Lot Block * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act. # Zone SF Project No. 6 Dwell # / No. of Buildings / Sq. Ft./Acre Depth /6'/ Frontage CC4 7 Set Back -Front I (L)S-1 (R)S-2 'Rear Census Tract IModule No. InitialsJ`?5Cr 16 Architect Firm Name To A/ SA. 4/ . a -e. A . t A . Street Address t,//5/ "TA/0 rC S9': Zip City�� (�� �� State l Phone (sem') s' -''S s -T2 D7 Contact Person . A! S Ake? e---, welt. Phone if different than above ( 1 Contractor Firm Name Cotreet 0 .1-k6� ,� A/ 4 Arf C..ti e71Q-c... e.-- "(---- e o rJ Address ...,_ Zip 2 AN Clty , /d o /`.PaIti� StatePhone 1oa (S'"©P) ‘ - .. !,,` ; C'"% --- Contact Person /ems �G N A /�) License No. , i /rt & �,c C -2 r cQ 2. 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 (Y/N) t SEPA Exempt (YIN) Date 15 Type WorkBldg 0 Fire E MH ❑ Demo *<ew ❑ Add/Alter ❑ Replace ❑ Move ❑ Other 14 Describe Work dsAICAZtr ,�/�71,pc4 Ai, �.v*. - '` ,' -' "4 ,d. 7 -41,1 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 PIF - 12' 10( -ZF _ !7cY /0U ,Q 11* e 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 O Commercial; • New Construction; O Additional structure; O Residential E Bldg alteration /addition APPLICATION # Release Release w/cond 1 Hold 2 111111111111 Conditions/Comments Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage; N. 721 Jefferson D 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; N.811 Jefferson D drainage O road improvements Conditions/Comments- D Residential; 0 Flood Plain; • new access/approach; 0 fence; /‹-A0C V? 0— Utilities: N. 811 Jefferson Conditions/Comments• Other: ci LI 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 r II1 N r 0 ti 0 � O �u `1 r fri a0 —1 — "V 0 a -2 T GO+�IKLIi�I iz) L th --... _