1984, 09-10 Permit App: 00002191 Replace Ceiling BUILDING PERMIT APPLICATION WORKSHEET e .
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
(5 Q/ l iflo Oi0 ,4. Ras. Comm
2 Project Address(not Mailing Address)a Road Name Space Zip
A) 5O`l SA)/y ,J 1 41
3 City/Community / State Subdivision/Plat Name
tfli _ //4 i JO S6MS A8C
4 Assessor Parcel No. Lot I Block
1 (� 4 7/ 7 4 ---10 75-FF f^ * * * DEPARTMENT USE ONLY * *
CDJ 5 Sic Code Zone Act.# Zone Project No. Z( ci t
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Back-Front 1(L)S-1 (R)S-2 I Rear Census Tract I Module No. Initials
r
* 16 Architect Firm Name Street Address
Zip City 'State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
, , SCS ; Q .Twc-- / ' Q0U k
Zip City State Phone
5,00 ,9 A) `L Le)c-kk_
Contact Person License No. _Phone if different than above
ie�Re
.1l tt A4 3v1 fl9J2sE ?r y -o7 8/ )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(YIN) SEPA Exempt(YIN) Date
15 Typ Work Bldg D M ❑ New ❑ Replace ❑ 0thar� 1.)� /1 I Q 0H ,
Fire D Demo ❑ Add/Alter ❑ Move �,de-Nr
I\ IT ,, • l
14 DescribeWork •n1,190 ..,-.
t }
YC 1- ��L 19c� 0 c_ - 1.;,1/4) 7 1 r c��{ 1�.�caJg ) W A i.1,S PR p411 i e
10 Applicant Name ' �J Street Address
11 Zip City State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
',-)A^1A) t 7-. 5 /000 `=