1985, 04-29 Permit App: 00005145 Remodel 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)/ y� (first) (m) Department Use Only
I�uGHSS 13Q0 — W
W . Ras. Comm
2 Project Address(not Mailing Address)a-Road Name Space Zip
. 3 00 a-- wcov(,O faviD t2-P
3 City/Community State Subdivision/Plat Name
VI of c AVO .
4 Assessor Parcel No. Lot Block
3 3. y j 2 _ 3 ?-05- I * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone r f(/ Project No.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Back-Front 1(L)S-1 (R)S-2 l Rear Census Tract Module No. Initials
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
lI ( )
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(Y/N) Other(YIN) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo Add/Alter ❑ Move
14 Describe Work
gf mbsT (2) -(Y)012E UN G
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
-4cD0 0°