1984, 08-23 Permit App: 00001919 Addition L
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 (last) (first) (m) I Department Use Only /y/G>
IDt‘(e.) VOm lY \`t✓ I Fps. ,/ Comm
2 Project Address(not Mailing Address)or Road N e Space Zip
. -g. I4Ta t \I a�tcA.3 wad min
3 City/Community 'l Stat- Subdivision/Plat Name
Ket
e. _ W A _ 6ark-
4 Assessor Parcel No. ` Lot Block
1� ,\4 - N -4 * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# L Zone Project No.
Ael.5ci r3
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
5+ AC..ia.E s
7 Set Back-Front (L)S-1 (R)S-2 I
Rear Census Tract Module No. Ipift
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firr3 Name I Aim Street Address
Zip City I State h Phone�� 2 2‘,-351
Contact Person License No. Phone If different than above
. 1 C-fit) - ZZ1 A-3..) ( )
8 Owner/Agent(if different than#1 above) J Oe,�^CJ�/�A6 4 Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check) Other(YIN) SEPA Exempt(YIN) Date
1 Com' 'I
15 Type Work Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire 0 Demo / Add/Alter 0 Move
14 Describe Work _
X1F�(! 6 1�'z1M ac�Y
10 Applicant Namee`Yom
eV
f..\r,�1,a\rcl `G -` Street Address
`C t C`J_y1t(_
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
Releasee w/cond 1 Hold 2
� D
Environmental Health ❑ Commercial; esidential Di
W.1101 College ❑ _,New Construction; ❑ Bldg alteration/addition ;f/)/,1d
Room 200 a Additional structure;
APPLICATION# 1$t%J/ 1 r�
Conditions/Comments:
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;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
coa
❑ Project Representative Telephone
Agencies Performing Special Inspection:
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2.
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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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