1984, 07-20 Permit App: 00001303 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 I Owner's Name (last) (first) (m) Department Use�nly
De-10)4e /i/'!__ J Fee. .V Comm
2 Project AddI ss( , ailing f.dress)or Road a Space Zip
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3 City/Community State Subdivision/Plat Name
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4 Assessor Parcel No. Lot Block
.0.----e---54-` --- k 2----? * * * DEPARTMENT USE ONLY ,t ,t *
5 Sic Code Zone Act.# Zone Project No.
6 Dwell ffNo.of Buildings Sq.Ft./Acre Depth/_.,�-,-�1 Frontage
I
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7 Set Back-Front I(L)S-1 (R)S-2 I Rear Census Tract Module No. 'ial
* 16 Architect Firm Name Street Address
4 )2G�/frt- - SSS
Zip City State Phone
( )
Contact Person Phone If different than above
Contractor Firm Name p_ Street Address
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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(Y/N) Other(Y/N) SEPA Exempt(YIN) Date
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15JJ�JT/,y��pe�W{ork,y�,� ❑ -Bldg ❑ MH D New E Replace ❑ Other
CG4� w44 SeA h-eOrwri ❑ Fire E Demo 18---Add/Alter E Move
14 Describe// Work
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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
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.) r
CI Fast Track
❑ ly Start --\-". Release
Release w/cond 1 Hold 2
i
Environmental Health ❑ Commercial; g R dentialSill $11�
W.1101 College CI New Construction; Idg alteration/addition
Room 200 CI Additional structure; - /('g ///���
APPLICATION# !w At L
Conditions/Comments:
O Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
❑ Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson CI drainage CI new access/approach; ❑ fence; l
❑ road improvements
Conditions/Comments:
III Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
ci.
c❑
o Project Representative Telephone
NAgencies Performing Special Inspection:
Y o
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0
1 E 2.
Co o
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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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DOROTHY E. 3AA-PT