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1984, 06-11 Permit App: 00000624 MH
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) 9ENrjE2gC N p G\` Department Only Fbs. Comm 2 Project Address (not Mailing Address) or Road Name Space Zip ©DZ 7v • �Ot� ` '25d2% 3 City/Community r_>`fl'S C3ee�aaos State Subdivision I Plat Name CkA — L-lT E �S'C'sr>C<rS 4 Assessor Parcel No. Lot I Block DEPARTMENT USE ONLY Zone Act. M Zone 2 X1-1 Project No. No. of Buildings 1F Sq. Ft./ Acre Depth Frontage 12U GZ ont p (L)S-1 (R)S-2 Rear Census Tract Module No. ais "7 rm Name Street Address City State Phone Contact Person Phone if different than above .Contractor Firm Name iA 6 Street Address +SCS ZIP - C"I Q 2 ULA City State Phone c ) 5 Contact Person License No. Phone If different than above 8 Owner/ Agent (if different than q1 above) �,JR Business Address 9 Zip City State Phone 12 Review Required Plan Check (Y N) .__-- Other (Y N) SEPA y� Exempt (Y/N) - Date 15 Type Work Idg Fire �. MH F' Demo New C Add/Alter r2 Replace 1:1Move Other 14 Describe Work Voc., r3� W I p C: M. N . 3-,4-x S�,_ 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 DEPARTMENT APPROVALS 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold I his Is not a rermit 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 I Release Release w/cond 1 Hold 2 Environmental Health W. 1101 College Room 200 ❑ Commercial; WResidential New Construction; ❑ Bldg alteration/addition ❑ Additional structure; APPLICATION fi Conditions/ Comments: ❑ 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: 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 1. O Z E 0 2 CE 3. 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold 1 E r+� 0 Q$ O JOEL RD 70• os' D w 0 t I i I N t 1 I i 1-1 el Ir Z IN N 1 q L N 1 I VI 1 1000 Ti6/1T GAr" auvE 1 � 1 n' � X 1 O i O 1 ` D