1984, 09-24 Permit App: 00002457 Addition 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)
7/ 1 Owner's Name 1A)0xrrf�(last) Department Use Only
(first) (m) I
// 2 Pr/ .Ad (not Mailing A ess)/or Road Na17 t r Space Res. Zip
Comm
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3 City/Community State Subdivision/Plat Name l
Vedic ! da l-e Leo , / /f'!'l ek/ t
\ 4 Assessor Parcel No. Lot Block
255 .3-
55 .3' 630 Q 1 3 * . * DEPARTMENT USE ONLY *
5 Sic Code Zone Act.# Zone / Project No.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ / /7i7O /COCA �d
7 Set Back-Front (L)S-1 (R)S-2 Rear Census Tract Module No. Initialsl
I
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Ai/i%—v�e a r1 J do i iia 1 Seg tit i -e i00 /30A, 7i/6 2,
Zip City State Phone
9 9°4 (3`� p CJ (1/7 Z-1)1'715.3 ya -S
Contact Person License No. Phone if different than above
CJQ�,' /.1.)1./J f r7'LL C., I-3 5�2 3 70 ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH 1= 1 w E Replace ❑ Other
❑ Fire ❑ Demo 8''''..-Add/Alter ❑ Move
14 Describe Work
z0 /f 1 idd 7c re51deoc eJ tiFe
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
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 ❑ Commercial; E Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION�#
c
Conditions/Comments: AA) C# /_ .i C(a �6�• �• vim '�2t J
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; I
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
T'-
❑ Plan Exam
Fire Prey.
Conditions/Comments:
a
c
Project Representative
Telephone
Agencies Performing Special Inspection:
▪ c 1.
0 '-
2 173.
E 2.
h O
LL
E
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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