1984, 11-30 Permit App: 00003563 Fire Damage RepairBUILDING 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 �rast) (first) (m)
C�
�•t. r-(1
Department Use Only
Fes. 1 Comm
2 Project Address Address) Road Name
(not Mailingor
V1\)A v 4,
Space Zip
` .
3 City/Com +nity
-S p�m✓�w, z
State
1/0L.—
SubdlvlsionlPlat Name
li All G11frtjt) '-fl IA -A
G O�
2 4 Ase 5- Parcel No. J 0'10-7
Lot 7
Block
• * * DEPARTMENT USE ONLY * *
5 Sic Code
Zone Act. If 4
Zone
Project No.
6 Dwell4
No. of Buildings
-Sq. Ft./Acre
Depth
Frontage
7 Set Bads -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contr or Firm NameStreet
Address
A/7 F 4_,m.
Zip
Ct A D
city
State1 -
v� c=L
Phone
( ) `C 2 J — P G I
Person
i\:_31....,
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) 1 SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bis19
Fire
D MH
0 Demo
❑ New
0 Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work ,\i� ► ' '
VJ fi r0
lrla/
'Q ;
10 Applicant Name
\\'�1� . om.
Address v
i/
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional 1 formation
1 o°e °J-
❑
❑
DEPARTMENT APPROVALS
Application Type
(Standard unless
otherwise indicated)
Fast Track
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Early Start
•
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
APPLICATION #
Conditions /Comments:
❑
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone; 1
I
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments:
❑
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
1 I
1
0 road improvements
Conditions/Comments•
❑
Utilities:
N. 811 Jefferson
I 1
l
1
Conditions/Comments:
❑
Other:
Plan Exam
Fire Prev.
•
Conditions/Comments'
1 Information E
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
ndicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold