1984, 11-14 Permit App: 00003347 Fire Damage RepairBUILDING 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)
(first) (m) Department Use Only
1 Owner's Name (last)
Res. 1 Comm
I
l
.l
Space Zip f
2 Project Adaaddaress (not Mailin dress o i oad Name Space ��/ �t CJ
—7 �- �" ei �� rd l 16
( l
3 /Commu y tate
I
Subdivision/PI me
orfciNl f /e174
Ar Parcel No. � N /
/ iiC
Lot
1 Block
* * * DEPAfiTMENT USE ONLY ,t **
5 Sic Code
Zone Act. #
Zone A
ctsul�
Project No. `
7? f/7
6 Dwell #
I No. of Buildings
Sq. Ft./Acre
I Depth
Frontage
7 Set Back -Front
1 (L)S-1 j(R)S-2
l Rear
Census Tract
I Module No.
Initials
w
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Contractor m Name
, ,
Stree
ddress
/
/.
Zip
/
CityState,
,5-7
Phone C(29
Cdntact Person
Li nse No.
Phone If different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
❑ New
❑ Add/Alter
0 Replace
0 Other
0 Move
14 Describe Work /— r
10 Applicant Name /�J
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Additional Information
'-e5--'
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold
chis is nota 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 ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
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; E fence;
❑ Other
Conditions/Comments•
❑
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson E drainage ❑ new access/approach; 0 fence;
0 road improvements
Conditions/Comments.
❑
Utilities:
N. 811 Jefferson
Conditions/Comments•
❑
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative Telephone
IInformation
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