1985, 04-30 Permit App: 00005186 AdditionBUILDING 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 Owners Name (last) (first) (m
Department Use Only -
Sow fiat) Q �xjmy«�
rte. Comm
2 Project Address (not Mailing Address) crRoad Name Space Zip
e t 3?Y IT Vh Iiss to 10
3 Clty/Community
& reeve n e_re 5
State
W 4
Subdivision/Plat Name
Corsi' 400 TO lrKee/vac se s
4Assessor Parcel No.
i
8 1755.1O -0102
Lot Block
(o )I1
t f ♦ DEPARTMENT USE ONLY *
5 Sic Code
Zone Act. N
Zone Aca11
Project No.
6 Dwell if '
No. o1 Buildings
Sq. Ft./Acre
Depth 1
1 G
Frontage )
206
7 Set Back -Front (L S-1
�I'�TINC �o'
(R)S2 Rear
- -
Census Tract
Module No.
Int al
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16 Arc'hitteectt Firm Name 11 �1 (���1'[���'�''
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Address
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Zip
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Contact Person
er i,
Phone if different than above
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Contractor Firm Name /.i/�•(,VY) A
Street
Address E /go z/ t t./t
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Zip
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City
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State
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Phone
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Person
Contact Person
• �
License No.
4.E/M✓w x aij 10 L
Phoneif different than above
( )
8 Owner/Agent (if different than Al above)
Busl
ess Address
9 Zip
City
State
Phone.
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) J SEPA Exempt
(Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
0 MH
0 Demo
❑ New
Add/Alter
0 Replace '
0 Move
0 Other
14 Descnb0rkgi7 /a r//Q,��r'�,_.�M'y eq'-J�
,/W�V�y����
10 Applicant NameV aS ACL treat
'1F
Address /• \
J
11 Zip
Su4-���
City
S Cs -vi C
State
S 0"•41LC-
Phone
( ) S C.4. -41-1.c_,
Lender / V V I
Ajo-n
Street Address
Zlp
City
State
Phone
Contact Person -
Phone if different than above
( 1
Additional Information //11 y�}--,,
17Xl� aciA. aot T 6 . op
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 ❑ Commercial; _ _ 0 Residential
W. 1101 College ❑ New Construction; 0 Bldg alteration/addition
Room 200 2 Additional structure; P
Releassej]t`
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/Comments.
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;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments:
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
❑ road Improvements
Conditions/Comments -
Utilities: s. _
N. 811 Jefferson
Conditions/Comments
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
w
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
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