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1984, 08-09 Permit App: 00001686 GarageI%" --I- BUILDING 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) I 1 Owner's Name , I (last)/ (first) (m) G/; �.I/ �; N� qG DepartUse Only Res. Comm 2 Project Address (not Mailing Addre3s) or Road Name Space Zip 3 City/Community State Subolvision/Plat Name , 4 Assessor Paroal No. © 9-3 !J �2_ _ 15 0 __22* Lot Block DEPARTMENT USE ONLY + 5 Sic Code Zone Act. M Zone Project No. 6 Dwell $ No. of Buildings Sq. Ft./Acre Depth Frontage 7 Set Bade -Front (L)S-1 (R)S-2 Rear 03nsus Tract Module No. Init Is 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 M1 above) Business Address 9 Zip City State Phone 12 Review Required Plan Check (Y/N) '4i5 C7 Other �(Y//N) SEPA Exempt (Y/N) Date 15 Type Work Bldg ElFire ❑ MH ElDemo New ElAdd/Alter ❑ Replace ❑ Move ❑ Other 14 Describe Work 10 Applicant Name t(Yti i� r<d��ti�� eti��a'�� Street Address N Yale 11 Zip Cit State Phone Lender Street Address Zip City State Phone Contact Person Phone if different than above Additional Information DEPARTMENT APPROVALS 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold Vol' Application Type i nls is not a Permit ❑ (Standard unless otherwise indicated) Fast Track (Indicated approvals required in either "release" or "release with conditions" space prior to permit issuance.) I - ❑ Early Start Release J Release w/cond 1 Hold 2 Environmental Health W. 1101 College Room 200 ❑ Commercial; Residential ❑ New Construction; ❑ Bldg alteration /addition 0 Additional structure; APPLICATION # Conditions/ Comments: D Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage; N. 721 Jefferson ❑Setbacks; Ellot w/d; ❑ lot size; Eluse/zone; ❑ CU, variance, zone change; shoreline; ❑ fence; ❑ Other Conditions/ Comments: ❑ Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; N. 811 Jefferson ❑ drainage ❑ new access/ approach; ❑ fence; ❑ road improvements Conditions/ Comments: ❑ Utilities: N. 811 Jefferson Conditions/ Comments: ❑ Other: ❑ Plan Exam Fire Prev. Conditions/ Comments: Project Representative Telephone Agencies Performing Special Inspection: c O 1. E `o 2 c 3. 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold Vol' - S- 4 s O AT'% O cr C;3 cr