1984, 08-30 Permit App: 00002077 ResidenceBUILDING PERMIT APPLICATION WORKSHEET Z "
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 is Name (last) (first) (m)
Department Use Only
1.-6, 0-- D v t lirT/"Rve_,'iA A
Res. Comm
2 Project Address (not Mailing Addr ) a Road Name Space Zip
3 C //Community
/1701a4/ o
-
State
C.f/A-
Subdivi ion/Plat Name
1//P,/eA41., 4/
4 Assessor Parcel No. , %Lj r- `.:'•
24 f 3 3 OS &
Lot H �/
S D e / /r
Block
f/e^ /t co
* * * DEPARTMENT USE ONLY * * *
5 � is Code �
Qlso
Zone Act. #
Zone � � � �
Project No.
7 7
6 Dwell #
l
No. of Buildings
l
Sq. Ft./Acre
Depth
(27 t
Frontage
68 t
7 Set Bads -Front
'7 S-- 1
(L S-1
[ \--I
(R)S-2 1
a
Rear
11
Census Tract
Module No.
Initials
Jo J j.
* 16 Architect Firm Name �7
.?Oft --/Ail 1P ,_P f/6 A/
( Street Address
1 /5/L( / 1%/ a/1 /#-
Zip
f « �—
City
9P,i d
State
LL/6t_(.
Phone
e
09) /(-g 7G# '
r�son /
Contact (j
*C _-'-1-;'/Z° /�t%
Phone If different than above
( )
ntractor Firm Name eel
/9 P'6.4" i--- /tOZ/,?...0.--
4,y ft:"
Street Address
4/ I_Aeri— PR 4 -/vg 4 -Ai_ /,'
Zip
f f f---_�p,J.ltya
City
State
LOA-
Phone
(s if) ."aG - y,2, a
Contact Person
7F,riP/-70.22 6,
Lice No.
/`7v.06t,(` e..--
j-3 /574
Phone If different than above
( )
8 Owner/Agent (If different than #1 above)
Busi
less Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y!N)
Other (Y/N)
SEPA Exempt (Y!N)
Date
15 Type Work Lk Bldg
0 Fire
0 MH
0 Demo
/f
-'New
0 Add/Alter
0 Replace
0 Move
❑ Other
14 Describe Work
//1) /% fri -ems
10 Ap licant Name
O�, ,� t,ff//1/..0G__
Street
Street Address
God _ jea/f/1/6"g-/
11 Zip
*-
'I9',�-
City
�P�L`,
State
a/ -t-
Phone
(J'd() J'..1 -G - I/2,1 a
ALender
t/Cf/�/5t#Ps
Street
hei.
Address - I
! v..r 1'
7r''
City
_7P4 _
State
/at_
Phone
(7) 71/ G 7 9' /
Contact Person
., it/c0 e/s''�/
Phone if different than above
( )
Additional Information /
..La7` / j ? t e.
e 69 aAA/ rTX/,o /5 g
I",oJ®c,0„Sl T 2s--/-/,
-
As- ef k -2- .405e. ,177 — /il ofp — .{7,/it/tic r //0Z/ -7s-..14
ECEIVE
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is 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
O Commercial; 0 Residential
❑ New Construction; 0 Bldg alteration/addition
❑ Additional structure;
APPLICATION # (y-�0 «7
4
Release
Release
w/ nd 1
Hold 2
0
Planning/Zoning:
N.721 Jefferson
Conditions/Comments
❑ Commercial; 0 Cert. of Exemption; D Frontage;
❑ Setbacks; ❑ lot w/o; 0 lot size; 0 use/zone'
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Engineers:
N.811 Jefferson
Conditions/ Com ments
❑ Commercial;
❑ drainage
❑ road Improvements
ElResidential;
❑ new access/approach
O Flood Plain;
O fence;
C
Utilities:
N.811 Jefferson
Conditions/Comments-
Other:
onditions/Comments-
Other:
Plan Exam
Fire Prev.
Conditions /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
F
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0
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0
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