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1984, 06-28 Permit App: 00000347 ResidenceBUILDING 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) Go L Da.) c,( j r Co cu re ci C%J O,(/ CO Department Use Only ✓ Comm 2 Project Address (not Mailing Address) or Road Name Space Zip .4c. o d- Ica bc5D12- ..F F - 0 3 City/Community Sp0KAu.E. State UJ 41, Subdivision/Plat Name Po, WEAaas q S r' I a�0-1.6Jt> 4 Assessor Parcel No. 4-5 ''.a (D( LotBlock / f * . . DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act. # Zone Project No. '774{ 7 6 Dwell $ k No. of Buildings 1 Sq. Ft./Acre Depth lSv Frontage k c5a 7 Set Back -Front I(L S-1 (R)S-2 j 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 GOC DENC,cg.S / COA/S-M.JGTro Co , Street Address E. o) 704/ 6 -'Lc Rb. Zip 9 9.,)O 8 city Spa A to E State I v'V 3 Phon ( sal'' ) 9‘‘--- CEJ CJ 1 f Contact Person „/osEph toy License No. £)3.0} 60lcEcc/ 7.ra8 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 (Y/N) SEPA Exempt (Y/N) Date 15 Type Work Of Bldg ❑ Fire ❑ MH 0 Demo -7 New - Add/Alter ❑ Replace 0 Move ❑ Other 14 Describe Work .S i iv 5•L r m, ii ,Q.c t, v.E ivC hJi..V;74 diE1> Gid df 19 6..C: 10 Applicant Name — S /M2 — Street Address 11 Zip City State Phone ( ) Lender COL V )41B/%4 S'EAe✓, cttr t9%D,ei.T, Co Street Address iV . .30C 4AZG0•Vnlg' RD Zip 9 9 a 6 . City 5 po ra,v� State Phone w n (so?) ?c)..)- ).2 a 0 Contact Person Phone if different than above .-Det/00 ,./0 Lh N1 oi✓ ( ) Additional Information 4,1_12_ Application Type (Standard unless otherwise Indicated) Fast Track Early Start DEPARTMENT APPROVALS Thiele nota Permit (Indicated approvals required In either "release" or "release with conditions" space prior to permit issuance.) Environmental Health W. 1101 College Room 200 Conditions/Comments. ❑ fLommerclal; leclesidential New Construction; ❑ Bldg alteration/addition O Additional structure;�f' APPLICATION # fr. V V.S7O 'elease Release w/cond 1 Hold 2 inwQb• • 0 Planning/zoning: 0 Commercial> 0 Cert. of Exemption; 0 Frontage; N. 721 Jefferson O Setbacks; 0 lot w/d; 0 lot size; 0 use/zone. O CU, variance, zone change; shoreline; 0 fence; O Other Conditions/Comments• Engineers: 0 Commercial;�/R�idential; 0 Flood Plain; N. 811 Jefferson 0 drainage IliieWaccess/approach; 0 fence; O road Improvements Conditions /Com menta - 0 Utilities: N. 811 Jefferson Conditions/Com ments• 0 0 Other: • Plan Exam Fire Prev. Cond itlons /Comments Project 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 • • • ei.ZCoA4s-7: _ ./J ;,P_6,14, / L MAI FL. L -E. 1 t 40 4— 00 no