1984, 05-01 Permit App: 00003905 Repair Fire DamageBUILDING 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)
Departmentt4Jae Only
-Far
Fee. ✓/
Comm
2 Project Address (not Mailing Address) m Road NIme Space Zip
9-920 f
3 Gty/Cam unity G�y�.�
StateU.10.
/
W
Subdivision/ Plat ame
S.— -4
yar ��2�� .
4 Parcel No. \
1-F-5-441,_ 7, 2--<— --
Lot
2 -
Block
J
* * + DEPARTMENT USE ONLY
5 Sic Code Zone Act./
Zone
Project No.
6 Dwell Y
No. of Buildings
Sq Ft./Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2mtd(Rear
4
Census Tract
Module No.
Initials
16 Alect Firm Name I Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
( )
Contractor Firm Name
E47� �1� �GC-j
Street A�c-7,9
7 c% �/�
•,a
Zip
7?27
Gr,
`
e
Phone -
.( ) 3-6�7y
Confect Person
4cense No.
Phone If different than above
( )
8 Owner/Agent (if differ than/1 above)
1/
Business Address
9 Zip
City
State
Phone )722 _ 7? 7/
12 Review Required
Plan Check (Y/ N)
Other (Y/ N)
1 SEPA Exempt (Y/N)
I
Date
15 Type Work 0 Bldg
XFire
0 MH
0 Demo
0 New _
0 Add/Alter
0 Replace.
0 Move
0 Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
1 )
Contact Person
Phone If different than above
( )
Additional Information
4 \bv b -D Uig 0616 rte
DEPARTMENT APPROVALS
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis is no' a rermit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; 0 Residential
W. 1101 College ❑ New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
APPLICATION #
Conditions/Comments.
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments:
Engineers: ❑ Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson ❑ drainage 0 0
I
new access/approach; fence;
0 road improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments.
t
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments.
IInformation ❑
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