1985, 01-28 Permit App: 00004065 Residence —IS
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) Department Use Only
al, /` r tc . Se- 4 SCCi S //tie Ras. Comm
2 Project Address(not Mailing A dress)Cr Road Na Space Zip
\l /7e 4c�k fildri Or C920-3
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. LotBlock
74-fes/ — 41*a I .3 * * * DEPARTMENT USE ONLY * * *
5 Sic Code 0 Zone Act.# Zone Project No. /�
-/ ` CIOLD
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ / NC C6
7 Set Bade-Front I(L)S-1 (R)S-2 I Rear Census Tract Module No. Initials
35 /5 2e — Q 1
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
'A frit-- - t3 . / lYe e v
Zip City State Phone
99L'V 5 rc irii,e% `;G/1fs ( ) .;2 y--6 7(V
Contact Person License No. Phone if different than above
161(1 -5,71/777f WK5A *2A5 ma 223°1 ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) SEPA Exempt(YIN) Date
15 Type Work 8"--Bldg ❑ MH New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
c,.L'E1 f. F=14,-1 /�/L t/ /`c cs foe/fief. LL/ D.er e /1.77-_ Chi .9/64_
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
-- Mf /?�/L / r i t \I .� t
ue / C- i i .) t t s,
i _ QA r � -- Qi760.____,--. '
r. U-
•
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
❑
fl Release� w/cond 1 Hold 2
Environmental Health Elfl Commercial; ❑ Residential .vim'
-15
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
p.4140-/L„
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
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:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; 1
•
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence; ' ilk
❑ road improvements
Conditions/Comments: /9V - 0.== / -t WA -
0 Utilities:
N.811 Jefferson
Conditions/Comments:
EI
Other:
❑ Plan Exam i t%•/
Fire Prey.
Conditions/Comments:
O.
co
c❑
Project Representative Telephone
�nAgencies Performing Special Inspection:
1.
Y O
U
O
E
2.
ro
LL
c
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
I--
2
t0 1 — .
v
1
Q
Q
111
1
{�
C t IN. ..
u t.
• o 1 -i _.� t 1
1
1 0,,, ri GeokAG7f,
GNL
f
' . a► J
-a 1
VI .it 4,/ - ivt)
1- f , ,
1 q 1,‘ - .)i) . -
i1 I
t
r'
1 i a
X00
, 00
/ 7 0 3 so /�oex /P_C ____-