1984, 10-03 Permit App: 00002634 GarageBUILDING 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 Owwnner'sName (last) (first) (m) Department Use Only
,p w�
/ •�/ e S/rA/ h/f/l Y r FSS.
I
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
CA -5— sX%rem ri42 d ANx� 0,4 s� ?'70, Ze
3 City/Community
ate
Subdivision/Plat Name
4 Assessor Parcel No.
or
2.T5-31- /oaf
Lot
//
Block
/O
* . . DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. ft
Zone �� A
Project No.
6 Dwell N
No. of Buildings
S'-
-Sq. Ft./Acre
Depth I
2210
Frontage i
1S
7 Set Back-Front(L
S-1 )
(R)S-2
I Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City I
State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different than 91 above)Business
Address
DAVE C.�,a'A 9'---V
//i1l,G'riV
9 Zip
City
A--12oa
State
//_,Ailo
Phone ,r
( ) 3 S- - 5 74-7
12 Review Required
Plan heck (Y/N)
Other (Y/N) SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
E MH
❑ Demo
❑ New
❑ Add/Alter
D Replace
❑ Move
❑ Other
14 Describe Work
00.1TIO 0 11 PCki .Y.19\ I K1/2f0 alkZE 2 4'( 2
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;
APPLICATI
❑ Residential
❑ Bldg alteration/addition
cal aw� 4GLt-itta-a
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; ❑ fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson 0 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 Telephone
Agencies Performing Special Inspection:
1
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Release
w/cond 1
Hold 2VtO,lir
Release
cal aw� 4GLt-itta-a
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; ❑ fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson 0 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 Telephone
Agencies Performing Special Inspection:
1
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold