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1986, 04-22 Permit App: 00010959 Residence (THIS IS NOTA PERMIT) BUILDING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND COMPLETE IN INK (Please return this original and your building plans to the Department of Building and Safety) SHADED AREAS ARE FOR DEPARTMENTAL USE .I 10�5�1 Project Number Owner's Name _A/,,, LAST FIRST MI � /fie. --" 790027 Project Address(Street Name&Number) Zip S. 7 5' 'rider/n 0/ Applicant Addr City State Zip Phone C IS CAZIna IOS Cul \ f d 9,7 ( 50? 9 .C)C/ Business Phone ( 1 Contractor/Agent Address Cl/d?6 City State Zip Phone ( 1 Contact License Number(Required) Business Phone \'‹MA.LAC-4C2.2 ,,(r ( ) Architect/Engineer Address City State I Zip Phone ( ) Contact Business Phone Lender Address City State Zip Phone ( ) Describe Work \ Res. Comm. 1 t-- in ; t r ICt `-}{ v R .,c ✓ Sub ivision/Plat Name/Short Plat Num r h td X74. � ;i 7 _ C9�_A) .z� S /�, Assessor Parcel Number LotBlock J Plat Number .1(54/., /3 S)S' y f Pertinent File Numbers Zone }� Comp.Plan Census Tract A/1 Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage P////// ZOO /c /ye/ , /' / -(7 /CO Front Setback , Left Setback t Right Setback Rear Setbacis R/W Width .' � 54> gs 40 Additional Information Square Footage Z 8104- --CI G 0 ~ a 80 = DECK 2 0 ; � u.Z , : a -J 5 m Number of Bedrooms is T Date Group T 4 r • DEPARTMENTAL REVIEW Approved Coed. Hold Approval 04if I r it Environmental Health Application# A' (r 4* • W.1101 College Room 200 Planning/Zoning ❑ N.721 Jefferson ,/ge — Engineers /� :V23 N.811 Jefferson K / 7 r Utilities ❑ N.811 Jefferson Plan Review/Fire Prevention ❑ N.811 Jefferson Other(SEPA/Critical Material/etc.) Fast Track/Special Inspection Information Project Representative Phone Address I certify that I have examined this application and state that the information contained in it and submitted by me or my agent to compile said application is true and correct. Signature _ c / I'LL" Date =?`1;:,2/18 4 -)/ )J Vh1FhAtv:Tuos Le 9 s n _,<,\ 1 ,.:(ft � . i 0-," i.,,--k-4,,AciS 1 . 1 Tr) --J a,?' I 4 � • 7 ,.i . `r` ! 6.1 i_.I s lee evil I�1/( ni"C f�' �1( I{ :jr1, E 1 1iX$ r,f_ //�yh' -x �1C1 '� 0, 7111.' .O (f-A`'`O hQb2 - �a b ' ' a �� �s CSs‘k. Lc/ hb -$fb }----- •�h ,j, „yl loc.- 0‘ °� `� f �, Lt°0bb i •O� 1 n ��}�,��a4�JJQ 5x-0 i -- - . - - - - - - - `� t� ...6.r4 0 X4 - - 71117 ly1 0O,I ,4 )"""' Ilk" ).41°44."/se _ - 8e s% 2 6 1d 141'4". **1°isUa� ;