1984, 11-08 Permit App: 00003275 Addition1
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)
/n��r's Name
j� 1)) (first) (m)
Io`"' N i� eA, ,C Cs -U �(✓ /l�lj- �Pf%
Department the Only
Fes. Comm
2 Proect Address (not Mailing Address) or Road Name Space Zip
AA 3� 3, & kJ /' l-1-114- rel s PS. 9901.0,4
3 City/ mmunity
�HH/a-N8,
State
Ge>y.
Subdivision/Plat Name
G2awn`1(C4J A - t
d Parcel No.�/
64643 - e 02 1
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act. N
Zone
Project No.
6 Dwell N
A
No. of Buildings
1
Sq. Ft./Acre
Depth
i2.0
Frontage
10
7 Set Beck -Front
(L)S-1
(R)S-2 (Rear
Census Tract
Module No.
Initials
9--a—
16 Architect Arm Name
Street Address
ZIp
aty
State
Phone
Contact Person
Phone If different than above
( )
Contractor Finn Name
Street Address
Zip
qty
State
Phone
( )
Contact Person
License No.
Phone If different than above
8 Owner/Agent (If different than N1 above)
Business Address
0 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N)
Other (YIN) 1SEPA Exempt (Y/N)
Date
15 Type Work '1 Bldg
0 Fire
0 MH
0 Demo
0 New
X,/ Add/Alter
0 Replace
0 Move
❑ Other
/ M
44dd./DescNGbek # Fi`-M; Lt,� &OM 6 /t% o Al !' Jit a
10 Anent Name
alb NA 73e4
G.2Gruson/
Street Address
/v'3 a--)-3 `t)7 Le--f4/12s,C
11 Zip
4/ q
/ (mo(,
Clty , /
�OF'(/fQ13'
State
e
LV f}
Phone
I ) 9aa_iais'
Lender
N67N(a-
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
Additional Information
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
l"
Environmental Health ❑ Commercial; Resldentlal
W. 1101 College Ai New Construction; Bldg alteration/addition
Room 200 Additional structure;
APPLICATION #
•
Release
Release
w/cond 1
Hold 2
d,A e
Conditions/ Comments.
0
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 12t -size; 0 use/zone'
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments•
Engineers: 0 Commercial; 0 Resldentlal; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Condltions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
Plan Exam
Fire Prev.
Conditions/Comments
Protect Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold