1984, 10-09 Permit App: 00002730 Garage 2-7sg3- 1 J1.1
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)
I 1 Owner's Na (last (first) (m) Department Use Only
I r N -(-)k-/ .&f QIJ p,tu C- 00 (+ lbs. Comm
2 Project Address(not Mailing Address)a Road Name Space Zip
- -- /v2gO 4- S lry Ul&-t t1 PiJ q'C( E
\ .
3 City/Community State Subdivision/Plat Name
S 'c k ccn..azo l---) , f I LL l/ �.S'T ..4
4 Assessor Parcel No.
1
27 S-4I Q Lot ( Block * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone c-'7 czie Project No. '7 3 G
6 Dwell U No.of BuildingsSq.Ft./Acre Depth 1 4. Frontage
f09
7 Set Back-Front (L)S-1 (R)S-2 Rear Census Tract Module No. Initials
g911N 15 ,.101 m .
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
( )
Contact Person License No. Phone if different than above
i ( )
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 Type Work ❑ Bldg 0 MH 0 New ❑ Replace ❑ Other
0 Fire ❑ Demo ❑ Add/Alter `�❑ Moove
14 Describe Work (2 �(,,.�Z A- -,C..4.14-- =.4-%
--y-. ��C 2_.4 \A
2A 14�t', 1 T C v,/. ^
10 Applicant NameStreet Address
CS U/N —cNi :; J'-E 7 J U — (,8 a 4- S(C 1 i U(etas 4-0-e-
11 Zip City State Phone
a<'.. 4 6 S Fa .=tom leCsO (. ') 4C 6. ._ .6(.-Q./
*
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
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