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1984, 09-18 Permit App: 00003857 Residence 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) I Im70fh y v `� ti, L— - Res. I Comm 2 Project Address(not Mailing Address)a Road Name Space Zip • 3 City/Community State Subdivision lPlat Name �=�'1�- r. c_.-) u tom' 3 3 Z 4 Assessor Parcel No. Lot Block j e 5--y/ 5-- Z 7' yaa? * * * DEPARTMENT USE ONLY * * it 5 Sic Code Zone Act.4 Zone CII • • Project No. s54:5-• 6 Dwell 4 No.of Buildings 1 Sq.Ft./Acre Depth Frontage 7 Set Back-Front 1 (L)S-1 t (R)S-2 l Rear Census Tract Module No. Initials O , 30 [� * 16 Architect Firm Name Street Address * Zip City State Phone ( ) Contact Person Phone If different than above ( ) Contractor Firm Name Street Address Zip City State Phone ( ) Contact Person License No. Phone If different than above ( ) 8 Owner/Agent(if different than 41 above) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check(Y/N) Other(YIN) SEPA Exempt(YIN) Date Yes 15 Type Work C Bldg 0 MH 0 New 0 Replace 0 Other 0 Fire ❑ Demo 0 Add/Alter Move 14 Describe Work „..../4- _-,c� t" �C �7 .-, t c { o' ^, .2-u // /�elS r"r».+ f 10 Applicant me ...-17,-,-7Street Address .0. - /c-,� ,-"" S- 3 z 3 i z �� ...-17,-,-711 Zip City State 'Phone 775'O 3 7 6_-2-,--- ,....)r , --�� (Sz35' ) 517 2 z Z 2_ 7 * Lender Street Address * Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Informati 4 tW i4 4":2--7`5_ 5 U— iNSpec'r(o A...) 4S(2 (2 S AMU 6 0 f1Z0 til = 13 e0,0,4- cv,> V 'r LILY -B 68 t-c" 9c© _i 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 ❑ ommercial; Residential _��� W.1101 College New Construction; ❑ Bldg alteration/addition QM/ Room 200 ❑ Additional struucture;;'* 1 / QM G' APPLICATION# /( 3 �t= �;7 Conditions/Comments: ,0-,'_ e. ,c, ; _.. F ❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ 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; /Kesidential; 0 Flood Plain; N.811 Jefferson 0 drainage new access/approach; 0 fence; " I ❑ road improvements Conditions/Comments: Utilities: N.811 Jefferson Conditions/Comments: Other: Plan Exam Fire Prey. Conditions/Comments: d c❑ Project Representative Telephone Agencies Performing Special Inspection: O c 1. E 2. 3 O u_ C 3. 1 indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold r / . .,_., $ .7 ___ w...Niiii c4 \ _ --43- A? li.'rAr 0\ /' 7"41P2 71.-,%-,Jelz u )4.9f N.a..✓ i 2dip 52 -eQS k-Y --- -.K , / ,cf•f-d 4.4Ad ,;v� lin; Mr z Mi I 0 f ' off / 1 1 •z-. ' zc ,- � ' 1 1 •-., - - v✓ — — — — , ./Q — —`cam Q! `V` ` V 1 gy -,, ''.29-917-6 7-rn CIL) ,1"--?--t 7-V/ .,--x-- r-,-, //. ,, & 4.111-9-kti_.9D e)ch? — 4 9 -fj ;