1985, 07-08 Permit App: 00006268 PoolI.BfSI- 2-36-1-_237/9 SI- i`7a�
2.3 2-q l0o 5
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)
giY4.014 1 L!///J AJ
Cepartment Use Only
Ras. Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
F/r'Go g /,,arkx// c,goi,
3 City/Community
G v«0O0aLos
State
Cc) >
•
Subdivision/ Plat Name /�
(% 49 4); P4! Qo�e%Y:o.J
4 Assessor Parcel No
' ecrl :_ 2-Q
Lot
O.
Block
/D ♦ r ♦ DEPARTMENT USE ONLY * * *
5 Slc Code
Zone Act. p
Zone
Project No.
6 Dwell It
/
No. of Buildings
Sq. Ft./Acre
Depth t
Zoe
Frontage
Iort
7 Set Bads -Front (L S-1
5 -Ar 9n NG - l6
(R)S-2 Rear
f-
census Tract
Module No.
Initials
u N
{N) _
16 Architect Firm Name Street Address
Zip
City
State
Phone
( )
Contac Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
Phone
( )
Contact son
License No.
Phone if different than above
( )
8 Owner/Agent (If differe than 411 above)
Business Address
9 Zip
City
State
Phone
( )
12 Reviewuired
Plan Check(Y/N)
Other(Y/N)
SEPA Exempt(Y/N)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
Other
14 Describe Work
I(C )< 3Z SWism MCN6 I'TOL
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
act 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.)
El
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
7. Additional structure;
APPLICATION #
mAt.
❑ Residential
❑ Bldg alteration/addition
elease
Release
wlcond 1
i
Hold 2
Conditions /Com men is •
Planning/Zoning: 0 Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑use/zone•
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments-
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson ❑ drainage 0 new accesslapproach; 0 fence;
❑ road Improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments-
0
Other:
onditions/Comments-
Other:
Plan Exam
Fire Prev.
Conditions/Comments'
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
Q00
s
4
A,
rs
perch
21g64$ fl4rraell
1