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1984, 07-09 Permit App: 00001068 Reroof 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 Q{ s I (last) (first) (m) I Department Use Only �f J�1 CO a/0J C.7. Fts. Comm 2 Project Address(not Mailing Address)cr Road Name Space Zip f/2,>`03-- 5,0i(/l (”Zoco 3 City/Com nit State Subdivision/Plat Name P©k4A) CO.4 sicyo i,,J ,g-cies 4--d )1 r/ok1 4 Assessor Parcel9/C //(A g Lot Bloc// * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act.# Zone Project No. f /L/`"�/�^/ it (Depth 6 Dwell# No.of Buildings Sq.Ft./Acre epttlh Frontage r "` / • 7 Set Back-Front I(L)S-1 (R)S-2 f Rear Census Tract Module No. Initials97#4.6 j * 16 Architect Firm Name Street Address * Zip City State Phone ( ) Contact Person Phone if different than above ( ) Contractor� cFirm Name Street Address t .Y.YU r7 C l i s c ., 1 o Lt..) T '-r 7 i 0 Zip City 1 State Phone Contact Person License No. Phone If different than above k2i IA %-t-irk :L"0 ( ) 8 OwnerlAgen (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 Type Work ❑ Bldg ❑ MH New ❑ Replace ❑ Other ❑ Fire ❑ Demo , Add/Alter ❑ Move 14 Describe Work. fa I T�,u-s 4 Stl-f.Anitto .a."te . iji ir l C)Oc 10 ' 10 Applicant Name , Stfeet Address T) 4-u Is . ( 1—FtJN i d--I o UKv u i t,,,,) 11 Zip City State Phone wt, "( 4-td 1,* d t�IC ifi 16 t.:. I/6 GL. (5°41 ) oZ(d+ * * Lender Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Information U V U A-Tli6 f = ' ‘' a! °A °j=