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1984, 12-19 Permit App: 00003771 RemodelBUILDING 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�layt) > <JG j''_i'G (first) �91 (m) Department Use Only Res. Comm 2 Project Address (not Malling Address) or Road Name i'/ > Space Zip 3 Gty/Co^mmu/n)ity State Subdivision/ Plat Name 4 Assessor Parcel No, / 00�1jS� Lot Block * * + DEPARTMENT USE ONLY + Act. M Zone Project No. I No. of Buildings Sq. FtJ Acre Depth Frontage F5deZone nt (L)S-1 (R)S-2 Rear Cansus Tract Module No. Initials m Name Street Address city 7State Phone ( ) Contact Person Phone if different than above Contractor Firm Name _7 Street Address I S Zip city < State Phone Contact Person . License No. Phone if different than above 8 Owner/ Agent (if different than N1 above) Business Address 9 Zip City State Phone 12 Review Required Plan Check (Y/N) Other (YIN) SEPA Exempt (Y/N) Date 15 Type Work ❑ Bldg ❑ FIre ❑ MH ❑ Demo ❑ New Add/Alter ❑ Replace ❑ Move E Other 14 Describe Workf _'D 5 7 % Gam" i� ` Gts % -- PIA 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 Inform tion Application Type (Standard unless otherwise indicated) ❑ Fast Track ❑ Early Start ❑ Environmental Health ❑ Commercial; ❑ Residential W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition Room 200 ❑ Additional structure; APPLICATION # Conditions/ Comments: DEPARTMENT APPROVALS This is not a Permit (Indicated approvals required in either "release" or "release with conditions" space prior to permit issuance.) u ■❑1 Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage; N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; ❑ CU, variance, zone change; shoreline; ❑ fence; ❑ Other Conditions/ Comments: �••a^•w•�• VV111111ulwal, u nesioenuai; u hlootl Plain; N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence; ❑ road improvements Conditions/ Comments: Utilities: N. 811 Jefferson Conditions /Comments: Other: Plan Exam Fire Prev. Conditions/ Comments: Project Representative 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 Release Release w/cond 1 Hold 2 Telephone