1984, 11-09 Permit App: 00003289 Remodelb7 pr`
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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)
`%\�-2 fl N e S P, C- lAA-JL1� P2 o to e -e- I
Department Use Only
Ras. 1 Comm
2 Project Address (not Mailing Address) a Road Name Space Zip
N is meiLee ctr" 770/
3- City/Community
err ezfJ Ail res
State
Co 74-
Subdivision/Plat Name ""
SlIll S1 , Sj7L-,-
4 Assessor Parcel No.
J — ;0 -
(7 7 C raI O v
Lot Bieck
Z
: ♦ + DEPARTMENT USE ONLY r * *
5 Slc Cade
Zone Act.
Zone
Project No.
6 Dwell If
I
No. of Buildings
(
Sq. Ft./Acre
-
Depth
Frontage
7 Set Back -Front
«45-1
(R)S-2
Rear
Census Tract
Module No.
Initials
4 Ur) rye .
16 Architect Firm Name I Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone If different than above
1 1
Contractor Firm Name
i
Street Address
Zip
sty
State
Phone
1 1
Contact Person
License No.
Phone If different than above
( 1
8 Owner/Agent (if different than #1 above) -
Business Address
9 Zip
City
State
Phone
(o_ -) FZ-g- »'2 Z
12 Review Required
Plan Check (YIN)
Other (Y/N) I SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
0—Other
14 Describe Work
-5°6E- -r - ilEMW LUAU
. -
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
uM,uAflof ._ t 200 °° ma& s
•
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions/ Comments:
O Commercial;
fl New Construction;
• Additional structure;
D Residential
O Bldg alteration /addition
APPLICATION #
Release
Release
w/cond 1 Hold 2
--------_
111111111111
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
c
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage il 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 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