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1984, 07-25 Permit App: 00001445 ResidenceBUILDING 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) 00 * 1Ow er's Na (last) (first) (m) L I Department lJee Only Rss. V/ Comm 2 Project Address (not Mailing Address) or Road Name Space Zip Zr hlJC.sS,> ir, tS..9.3< 3 City/Community S k '''—‘7 c r16) State EL) Subdivision !Plat Name j� d / / SI / `. cd ; I b 6> ., >^1 ev/ /7 ci h . On ���,Assessor Parcel No. Lot Block * * * DEPARTMENT USE ONLY Project No.1 .4 .1 5 Sic Code Zone Act. # Zone 6 Dwell # No. of Buildings Sq. Ft./Acre Depth _ 1 7 Set Bads -Front (L S-1 2.3 (R)S-2 (5 Rear l Census Tract Module No. Initials 16 Architect Firm Name f Street Address fl Zip City State Phone ( ) Contact Person Phone If different than above ( ) Contractor Firm Name c-- 1. , C. Y 4s -cc, AIrS -7 Street Address >1O'• 1j.G /L0 g 57 Zip 0/ 9/ City S,ab 17 e., State (i)c._ Phone ( ) 92-�9 s� , { Contact Person G; i f t CYrf : it—�t License �lo. Phone if diff rent than above ( ) 8 Owner/Agent (if different than #1 above) S14,1�. Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check (Y/N) Other (Y/N) I SEPA Exempt (Y/N) Date 15 Type Work ❑ Bldg ❑ Fire ❑ MH ❑ Demo >rNNew ❑ Add/Alter ❑ Replace ❑ Move D Other 14 Describe Work S 111 /--- r Q ] / % 1 C_ r M , l,/ /1 4-i r(lei-, c-' to- GG%/f/1'•i��t' h e CI G.-a/Y.' y 4 _. 10 Applicant Name Street Address 11 Zip City State Phone ( ) Leder LL. yn 6 . a ce v v , c s Street Address R Y. ,.3 (`j c: A h c� c� .1 �^ v_ /t.., a . Zip (} /! City State Phone Contact Person JtA t.�►J .. r9 1 PI S el IA Phone if different than above ( ) f" Additional Information Vtt i(` ci TECCIVE"=,� u( � ��� , JUL51984 ,-- --)=�� E C E I V E =.. 00 * 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.) Environmental Health W. 1101 College Room 200 ❑ Commercial; ❑ New Construction; ❑ Additional structure; ❑ Residential ❑ Bldg alteration/addition • Release Release w/cond 1 Hold 2 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; 0 fence; O Other Conditions/Comments. Engineers: 0 Commercial; 0 Residential; ❑ Flood Plain; N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence; O road improvements Conditions/Comments. Utilities: N. 811 Jefferson Conditions/Comments• Other: Plan Exam Fire Prev. Conditions/Comments• Project Representative Agencies Performing Special Inspection: 1 Telephone 2 3 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold t3 7�- c/ pod _Si V 4 k /411)1 1 001 Sc g/1✓ /Mem,/ /0/ 11/1,4its Sic/ 07 1/,3 7 Cf ,t? •00