1984, 10-09 Permit App: 00002734 Residence Addition r • ,
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 y-9� (last) � � (first) (m) Department Only
T/2� 6asJ\ —A Z7C '7C /c./► - F63. Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
/7q , /e/U 111fJy
3 City/Community State Subdivision/Plat Name
.Sj7ejlieljs/V - •LF rC/i4l/e-FSS) 414- - /P6E-V,dGeF9 /, /f141/O ri/ Pj'/5Tie. -•
4 Assessor Parcel No. Lot Block
755`! - , YZ3 * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No.
A—C-ttZt
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
1 Z- Z l'-i"46. ‘Z- C) CO 00
7 Set Back-Front 1(L)S-1 (R)S-2 l Rear Census Tract Module No. Initials
*
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Q/1k/ ae./7/oN /7!=i«_ 1J_ 0201 Co,eA-
Zip City 1 State Phone
q/1ZdS S,OKAA/E___ /m,4- . ( ) 3Z7-48o1
Contact Person License No. Phone if different than above
,L7 f/e."--20_5 6-eA/57e#ZD / 7 ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) I SEPA Exempt(YIN) Date
15 Type Work ® Bldg El MH El New El Replace ❑ Other
❑ Fire ❑ Demo IP-Add/Alter ❑ Move
14 Describe Work
ADP //5G 2- 5 7 t 6) 4 oN .xisr4 /- F-f_.
10 Applicant Name Street Address
N..5rz-t/c--7?aN ILa_s 324 ao e-4
11 Zip City State Phone
I!
*
Zo.S ono(</vE-- �/4 . ( > ,3Z.7 - 1
Lender Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
N—S7 'e1 `aN / A . , 2V /A/ 3 p 5 ./410_5 -- /
/d/L/ t3. 717,1-e.- 21�57a2, -5.9f..-CG 1v/F/Jv/s.4) ,I , efe,t_ —P, .S&.
2 l.5 , , e' 1--�/it ( ' 5h'r 1�2) /e71/P5 ._ 3 /_, /v/Sf le,
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• 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 ElCommercial; E esidential (11 ,
W.1101 College ❑ New Construction; e Bldg alteration/addition
'
Room 200 IDAdditional structure;
APPL TION# S�' 7-40
" PALL?
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Conditions/Commen s: . : � �,,. �� �,�_� ( .`�: t 416
/ r
❑ Planning/Zoning: ❑ Commercial; 0 Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; ,
❑ CU,variance,zone change;shoreline; 0 fence;
O Other
Conditions/Comments:
❑ Engineers: ❑ Commercial; 0 Residential; ❑ Flood Plain; I
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
❑ Other:
z
0Plan Exam
Fire Prey.
Conditions/Comments:
coa
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Project Representative Telephone
Agencies Performing Special Inspection:
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. 2.
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3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold