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1985, 03-13 Permit App: 00004457 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) 00 1 Owner's Name (least) (first) (m) Department Use Only c" --14 4-E--5 1A./.,---,-- — //t✓ c - Res. Comm I 2 Project Address (not Mailing Address) cr Road Name Space Zip E, // 7'23 .e7//4"/ Cc,c_,R ; 3 City/Community 5.-/--c55.-/--c5/€04 it/Lc State / - �/4 Subdivision/Plat Name /2744 n 4e' 3 174> 4 Assessor Parcel No. - Qettr 9 D©?, 36'1'1, Lot ill Block a * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act. # Zone ' Project No. !s J7 6 Dwell # 1 No. of Buildings I Sq. Ft./Acre Depth Frontage 7 Set Back -Front (L)S-1 30 /7 (R)S-2 /3 Rear 5 Census Tract Module No. Initials Graz) 16 Architect Firm Name Z ? /4 ,---.,----,-,1,./-:; f .Z7GS/C tet/ Street Address Ai ' c'.$ "— Tom: / / j , o A-) Zip F 72c c3 City 5J'�G, ,4--i4.4...i. State GC//? Phone C" ?') 'z/ 7 — G :ex, , Contact Person 4-//./ S/%� i Al Phone if different than above ( ) Contractor Firm Name /7C3i°0-7_ 5- Ge,/, --ST ,,..-1-1C- ,. Street Address /''c", �cx J"----' 7 Zip ?-?c'',, City / C;fz�„•i- c /FE State Z -C Ji4- Phone ( d 2'2.,-/ — z/d c5' _5 --- Contact Person License No. //y7 syr,' Al . G7 -c” -//42E/3,Pr—./•vr— rAir;,,+G 1'w z l 7 y �u Phone If different than above ( ) 8 Owner/Agent (if different than #1 above) Business Address 9 Zip City State Phone ( 1 12 Review Required Plan Check (Y/N) Other (Y/N) SEPA Exempt (Y/N) Date 15 Type Work la' Bldg ❑ Fire ❑ MH ❑ Demo 'New ❑ Add/Alter D Replace E Move ❑ Other 14 Describe Work /F 10 Applicant Name 57 #9s #1 Street Address 11 Zip City State Phone ( ) Lender Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Information , Vii F 7/9 L /z,l ;, 57C //�,- DEPARTMENT APPROVALS 1 Indicate above or attach conditions relative to final as built approval 2 indicate above or attach reasons for hold Application Type (Standard unless otherwise indicated) Fast Track Early Start I iris IJ rtut ct rur wit (Indicated approvals required in either "release" or "release with conditions" to issuance.) space prior permit Release Release w/cond 1 Hold 2 Environmental Health ❑ Commercial; ❑ Residential W. 1101 College ❑ New Construction; 0 Bldg alteration/addition kV Room 200 C Additional structure; APPLICATION ,# Conditions/Comments. . ,c /Ctu--tY ❑ Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage; 0 Setbacks; ❑ lot wld; 0 lot size; ❑ use/zone; N. 721 Jefferson ❑ CU, variance, zone change; shoreline; 0 fence; 0 Other Conditions/Comments. 4 1 - Engineers: 0 Commercial; 0 Residential; ❑ Flood Plain; N. 811 Jefferson ❑ drainage ❑ new access/approach; 0 fence; 0 road improvements - /� Conditions/Comments• / 414 ^ 7� ❑ Utilities: N. 811 Jefferson Conditions/Comments' Other: ❑ Plan Exam oZeiW.T. Fire Prev. Conditions/Comments: Information Q1 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 1.• 4077- ,gocA-. 2 4/447/ E. 414./23 ,0,-4/v4 A