1984, 10-02 Permit App: 00002226 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
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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 Na e (last) (first) (m) Department Only
�' Fbs. Comm
I
W• C �S'SC>C i z 1,I �h e t
,
2 Project Address (not Mailing Address) cr Road Name Space Zip
e
/7Z -I! ,c/v4/ ,
3 City/Community
State
SubdivisiqPlat Name e., dip,
4 Assessor Parcel No.
fi 7
-2 (r5 I _ 14
Lot
Block
/ /
* * * DEPARTMENT USE ONLY * * *
c Code
5 Si2060.
,X)
Zone Act. #
Zone )2
Project No. �2j
G
6 Dwell#
No. of Buildings
I
-Sq. Ft./Acre
Depth
,4-c)c
Frontage
ZO i
7 Set Back -Front
I (L)S-1
(R)S-2
I Rear
Census Tract
I Module No.
!nit'
16 Architect Firm Name
Street Address
Zip
Gty
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name �J /
Street Address 2 -
Zip
9Z -/T
City -
3.42c)3.42c)/�` "fie,
State
(0(02_
Phone �y
(_So�i / ) 92 '�^ (7d
��t� Pgrson�
7
License No. — )
Phone if different than above
8 Owner/Agent (if different than 81 above) C / g)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work
A Bldg
❑ Fire
❑ MI -I
❑ Demo
X New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
S3,797c. �i77; A.. -Pc,) P J/; o / lict, J 9st� a q e 5
10 Applicant Name /j�
(e) . ,S a` �Y Cc n C, i / ! c
Street Address
11 Zip
City "—
State
Phone
( )
Lender
l.c)/Ce.ex7 .6";e._cQC '/Cep
Street Address
�p
360 41. iii--%�s?iio /I CY.
Zip
City
State
Phone
Contact Person 1
/9
("c�17 ✓�9 fi n Q �, 6-i
Phone if different than above
( )
Additional Information
151
mf =
I3 1740
fF2 sus g
U63 _ I200 %
6 OIL -- 44
*
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
rnis is not a Permit
❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
•
Early Start
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ �mmercial; Residential
W. 1101 College tI New Construction; D Bldg alteration/addition
Room 200 ❑ Additional structure;
//
APPLICATION # g « �j v O 6
/
Conditions/Comments %.i ,/ 4/!4/,..0 ...eat .0,0 ,r 4, g
❑
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
,
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments-
onditions/Comments
.
V1
L
Engineers: ❑ Commercial; idential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage new access/approach; 0 fence;
0 road improvements CC//
Conditions/Comments. /--'-/VAI — 5 b
•
Utilities:
N. 811 Jefferson
Conditions/Comments
❑
Other:
•
Plan Exam
-0/ -FY
Fire Prev.
r,�
Conditions/Comments-
Project Representative Telephone
1 Information
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
o
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3
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