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1985, 05-14 Permit App: 00005400 Addition
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) 1 Owner's Name (last) (first) (m) , � +liu� ,L ( Department Use Only Fts. Comm 2 Project Address (not MailinglAddress) or Road Name Space Zip 5• it 7(v 4-1 (4 wT v ('O u v+- 4a.J.o(P 3 City/Community I 3 p, k 14 State'Q, (V A— Subdivision/Plat Name / ) (y t gi-t )` Scr ie 5_- 4 Assessor Parcel No. 0 z4�{ 4 D --1.©% Lot ((.O Block * * * DEPARTMENT USE ONLY 5 Sic Code Zone Act. # ZoneeProject No.V O 6 Dwell # No. of Buildings SFt./Acre Depth Frontage 7 Set Bade -Front V)(/42T106 I (L)S-1 (R)S-2 Rear Census Tract Module No. Initials 1 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone If different than above ( ) Contractor Firm NameII t it 4 tG 1. ,.S Street Address (GA ) y ((o fl L Zip \ Qu � l g —D1-50 CityState Ica' -e.. I GQ -JA , Phone (5-z-91. > ofG7 -.'3Q co Contact Person ' i)d `"� 11 License No. t ILJC9 13 ,a v t C 3 Phone if different than above ( ) 8 Owner/Agent (if dif rent than #1 above) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check (Y/N) Other (Y/N) SEPA Exempt (YIN) Date 15 Type Work . Bldg 0 Fire ❑ MH ❑ Demo 0 New Add/Alter 0 Replace ❑ Move 0 Other 14 Describe Work 2_02 .p-- o n fit / ( g-ectre-75-K, -1-- \ 70111 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 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; ❑ New Construction; ❑ Additional structure; APPLJCATION #, /3 ` (13 Planning/Zoning: N. 721 Jefferson ❑ Residential ❑ Bldg alteration/addition bei/ro-n, „_s Release Release w/cond 1 Hold 2 k`/ 6//Th%li ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage; O Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone; ❑ CU, variance, zone change; shoreline; 0 fence; ❑ Other Conditions/Comments• J Engineers: N. 811 Jefferson O Commercial; 0 Residential; 0 Flood Plain; ❑ drainage 0 new access/approach; 0 fence; O road improvements Conditions/Comments• Utilities: N. 811 Jefferson Conditions/Comments• Other: Plan Exam Fire Prev. Conditions/Comments Project Representative Agencies Performing Special Inspection: 1 Telephone 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold