1984, 09-21 Permit App: 00002414 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) r Department Use Only
Vv)lir e.k.. labert .. f Fbs. Comm
2 Project Address(not Mailing Address)Cr Road Name Space Zip
3 City/Commuunnniity State Subdivision/Plat Name i / ^^�, r��rte/
4 r
4 Assessor Parce eio.A.
Lot W Block In ! ✓, 1� acid it o i (J(.Tt;,i,.t./j'+tt ?
!J 51./
1./2 -.2
24tq f `r I /7 * * * DEPARTMENT USE ONLY * * ,t1
5gCSic[Code`/ Zone Act..# Zone ✓ / Project No.
/At 6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
M 7 Set Back-Front I(L)S-1 (R)S-2 I Rear (census Tract Module No. Initials
* 16 Archil Firm Name I Street Address
Zip (Lr,0 l.X A State �J �
Phone
g l 5 O
1 i (�J77 _ ( .5—.09
) Q —os3 O
Co act Person V/6 Phone If different than above
( )
ntractor Firm Name Street Address
') :76' #//
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) l SEPA Exempt(YIN) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ,e/Add/Alter ❑ Move
14 Describe Work "I� 6 Att �� j, ��,
Li 1 l,r, �l - 112,10y Qe nf/1'1 /eytAcoci a#/►1 K I L ur•� b l Ali f�ki 4d�k1�•
10 Applicant Name / Street Address rj
11 Zip City State Phone
9 1 al to Sp ara4- ci A" ( ) qq k- i it 2
* Lender Street Address
Iv
iCYAL
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information -
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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.)
111 Fast Track
Early Start Release
9).erRelease w/cond 1 Hold 2
Environmental Health ID Commercial; CI Residential
W.1101 College CINew Construction; CIBldg alteration/addition
Room 200 El Additional structure,Li
APPLICATION#
Conditions/Comments:
Planning/Zoning: ❑ Commercial; El Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; El lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
. N.811 Jefferson CIdrainage Elnew access/approach; ❑ fence; I
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
a
To
❑ Project Representative Telephone
0. Agencies Performing Special Inspection:
Y O 1.
O '
f0 79
E 2
y
u0c
u_
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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