1985, 03-12 Permit App: 00004439 Repair Fire Damage r
j 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' Name (last) (first) (m) Department Use Only
L_ Fps. Comm
LT
2 Proj rasa(n Mailing Address)ar Name Space Zip
3 CitICo unit State State Su IsionlPlat Name
4^\ Parcelel
No. Lot Le/q".._ Blockon et
li%r eV /S
x54 -`/ ^ /F)) / / * . . DEPARTMENT USE ONLY * * *
5 Sic Code L� Zone Act.# Zone Project No. 41/2
6 Dwell# No.of Buildings Sq.Ft./Acre , Depth Frontage
/v`J�676
7 Set Back-Front I(L)S-1 (R)S-2 I
Rear Census Tract Module No. Initial
t / 7Z&
* *
16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
,
ntractor Firm a Ze,„,__„..rtedStreet rens i�
Zip Cl State P one
Contact Person License No. Phone if different than above
( )
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 ❑ New ❑ Replace L -r-
Other
❑ Fire ❑ Demo "Add/Alter ❑ Move
14 Des ibe Work
> re, Cl('niet e, res
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
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