1984, 11-20 Permit App: 0003637 Remodel 4
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) I Department Use Only
?X1-0/1�J Ras. Comm
2 Project Address(not Address)or—Road Name Space Zip
:5--- 6 yg /9-,Eo19-)QQ1II
3 Gty�mu�ty���� State�� Subdivisionl Plat Name
4 r Parcel No. Lot L/ Block
/35-13a - /6" * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No.
6 Dwell 11 No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Back-Front I(L)S-1 (R)S-2 1 Rear Census Tract I Module No. Initials
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
, Contact Person Phone if different than above
( )
Contr irm Name "'FA(�& / .ii7 7,85 - / 7
Zi / City State Phone ) ! / �-&9
rte/ 64x, �'
/r
se No. Phone If different than above
I Z32-11 614443 (le L 1/6 -42c4 17A/ ( ) q z 7
8 Owner/Agent(if different than 01 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) I SEPA Exempt(Y/N) Date
15 Type Work ]K Bldg 0 MH 0 New 0 Replace ❑ Other
/❑ Fire ❑ Demo .Add/Alter ❑ Move
14 Describe Work I t\ 0rti p G - Wsm ury fir( -�jJ,E
10 Applicant Name l J Street Address
11 Zip City State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information 00
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•
DEPARTMENT APPROVALS
This is riot a Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Track
❑ Early Start Release
ielease w/cond 1 Hold 2
❑ Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
❑ 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 ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
❑ Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
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0] Project Representative Telephone
• Agencies Performing Special Inspection:
O• c 1,
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3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
1