1985, 01-03 Permit App: 00003840 Fire Damage Repair Gd vrt - 1,100
BUILDING PERMIT APPLICATION WORKSHEET 'R+
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) I Department Use Only
TO 1-ti e I— Ivies A y Fps. Comm
2 Project Address(not Mailing Address)a Road Name Space , Zip
A3 Is' 06 e.r/�i-1✓ cS�'ioc ,51--v .Q___.- ? S 2.a 4'
3 City/Community State Subdivision/Plat Name
0',6(3KA& .t), ( J'9
4 Assessor Parcel No. Lot Block
5 Lt �f - 2 i O 01 - 4) ,t ,t ,t DEPARTMENT USE ONLY ,t * ,t
5 Sic Code [ T Zone Act.# Zone Project No.
g 10
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Bads-Front l(L)S-1 (R)S-2 l Rear Census Tract Module No. Initials {{ �//��/N
* 16 Architect Firm Name Street Address *
Zip ' City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
( )
Contact Person License No. Phone If different than above
6.141 L 1oto1 ( )
8 Owner/Agent(If different than#1 above) 4(/'OS' Business Address
9 Zip City State , Phone
( I
12 Review Required Plan Check(Y/N) Other(YIN) I SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ❑ Other
A Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
,4-'-e C-1/9,/;" 7-;9 _ -lc
10 Ap licant Name _/ Street Address
3 c `./e:-.,7,.111 G��J'T ,2% J' Ur()/vErs2'l
11 Zi City State ' Phone
>120 6- `('Dodit",9 4,-C'_- LA) y9 (6T17) 2.s:;- J T%d
* *
Lender Street Address
Zip City State Phone
( 1
Contact Person Phone if different than above
( )
Additional Information
-# 110 I OQo 2 I N't(Lto rk) (7. PADOIF'ttJ—i k) " CAST
CAO cr l_Ur►it3 )
•
DEPARTMENT APPROVALS
This is nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Track
❑ Early Start Release
Release w/cond 1 Hold 2
Environmental Health 0 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 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU,variance,zone change;shoreline; 0 fence;
O Other
Conditions/Comments:
❑ Engineers: 0 Commercial; 0 Residential; 0 Flood Plain; I
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
❑ Other:
Plan Exam
Fire Prey.
Conditions/Comments:
a
ca)
Project Representative Telephone
0. Agencies Performing Special Inspection:
c 1.
O
0 '-
2.
O
V_
3.
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold