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1985, 05-01 Permit App: 00005202 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) #i.e7411 e/ eY Lee"a Department Use Only Res. Comm 2 Project Address (not Mailing Address) a- Road Name Space Zip ire /7 ti1N,ete (1Q2/-- 3 City/Community ' State �, --'ms&- Su Ision/Plat re Name i vg 4(1(1 r/Gi' , 6 tr/ A 4 Assessor rcelNo. G)�5/ _ �Z / / Lot Block * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act. S Zone 2 Project No. 1 6 Dwell #No. / of Buildings /) Sq. Ft./Acre /, //t(V Depth Frontage 7 Set Back -Front I (L)S-1 (R)S-2 [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 / Gty_ State Phone L�nt son 1 ek License No. l4'& 5 /J:2'/ Phone If different than above ( ) 8 Owner/Agent (if different than #1 above) �i / X77 f 4 Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check (Y/N) Other (Y/N) 1 SEPA Exempt (Y/N) Date 15 Type Work 17"BIdg ❑ Fire D MH ❑ Demo ❑ New d/Alter ❑ Replace ❑ Move ❑ Other 14 Describe Work k2e5 ick.(' s (C/C/ /Q8 0 10 Applicant Name Street Address 11 Zip City State Phone ( 1 Lender Street Address Zip City State Phone ( 1 Contact Person Phone if different than above ( ) Additional Information 1 DEPARTMENT APPROVALS J ❑❑ Application Type (Standard unless otherwise Indicated) Fast Track Early Start • This is not a Permit (Indicated approvals required in either "release" or "release with conditions" space prior to permit issuance.) Release Release w/cond 1 Hold 2 El Environmental Health ❑ Commercial; ❑ Residential W. 1101 CollegeA ❑ New Construction; ❑ Bldg alteration/addition Room 200 ❑ Additional structure;j� i Ag AO 'd ( APPLICATION /r ( lam' Conditions/Comments: • Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage; N. 721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone; ❑ CU, variance, zone change; shoreline; ❑ fence; 0 Other Conditions/ Comments• Engineers: 0 Commercial; 0 Residential; ❑ Flood Plain; N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence; 0 road improvements Conditions /Comments Utilities: N. 811 Jefferson Conditions/Comments• Other: • Plan Exam Fire Prev. Conditions /Comments: 1 Information ❑1 Project Representative Telephone 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 kkg ev"tn