1984, 05-21 Permit App: 00000294 Addition •
_ 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
,; 4 } Fids. Comm
2 Project Address(not Mailintj Address)or Road Name Space Zip
3 City/Community State Subdivision/Plat Name
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4 Assr Parcel No. Lot".,„) Block
z j 5 1 - I 't D z... * * * DEPARTMENT USE ONLY * * *
Xi 5 Sic Code Zone Act.# Zone Project No. ,,..7 G� L
'— /�1
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
X 7 Set Back-Front I(L)S-1 (R)S-2 r Rear Census Tract Module No. Initials
* 16 Architect Firm Name Street Address *
L AAA . 4 O 'A/C IC
Zip City State Phone
( )
Contact Person Phone if different than above
( )
C?ntractor Firm Name Street Address
A
Zip City 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
( )
' 12 Review Required Plan Check(YIN) Other(Y/N) SEPA Exempt(YIN) Date
15 Type Work D Bldg D MI-I ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo X Add/Alter i ❑ Move nj
14 Describe Work 'J 1 "
aJ : ' �-'; -° `7' ,i 2Z X. to , ( Y, : 1 \i z,-1,
10 Appli nt Name Street Address
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11 Zip City r State 'Phone
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* *
Lender Street Address
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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
Release) w/cond 1 Hold 2
0 Environmental Health ❑ Commercial; ❑ Residential c54t"
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure; UU
APPLICATION#
Conditions/Comments:
❑ Planning/Zoning: ❑ Commercial; 0 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: ❑ Commercial; ❑ Residential; ❑ Flood Plain; I
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:
a
C
a); Project Representative Telephone
a Agencies Performing Special Inspection:
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2.
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LL
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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