1985, 06-28 Permit App: 00006157 Remodel A
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) Department Only
AlligeW (x',1'1 PE' .3 F' P i-* `., Res. 1 Comm
2 Project Address(not Mailing Address)or Road e Space Zip
, . , 1/( VtinA V`e± i'v e cfq(D3
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. Lot Block
/ .Z.5 5 �—��( ,c t/ i * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone V Project No. .•.
5 E,� ';'N:12(1-4,1HA1' t �1 J/ /
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
_ 1� 3 `
7 Set Back-Front 1(L)5-1 (R)S-2 Rear Census Tract Module No. Inipets
*
* 16 Archit irm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
1� ) g1 ' SP II/0 -
Zip City I State Phone '
Contact Person License No. Phone if different than above
( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
i
12 Review Required Plan Check(Y/N) Other(Y/N) 1 SEPA Exempt(Y/N) Date
15 Type Work ,2 Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo �i• Add/Alter ❑ Move
14 Describe Work / 0I t-
1 vlfq& k 11 ---e- Lwt , A-, 2-2- -/r-\ In Ici�e-/ -2.— 1'>`n/5V1 Yc7h' � `1'6'x(
10 licant N e Street Address
t<r,tber rC's S, c //O Vera 0 r ---,-7`�L r I v
11 Zip City StatePhone
Cl9' ',3 Ver�r ( LJa 5 h •. ( Jt'�"' (7 R•- l 1 q
LenderStreet Address
is-
g� � /716--: �ec�c� �,f` -- l`Ec � l /O Gro ve
Zip City Staten Phone ci,203
ntact Person Phone if different than above
Additional Information
. 1 �
DEPARTMENT APPROVALS
This is not a Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.) r
❑ Fast Track
Early Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments: CSE
El Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; 0 fence;
❑ Other
Conditions/Comments:
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
. N.811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
6,21—
Plan Exam
Ar-115ZFire Prey.
Conditions/Comments:
c❑
Project Representative Telephone
0. Agencies Performing Special Inspection:
Y O
c 1.
i-- E
2.
"in-
,
3.
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold