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1985, 11-18 Permit App: 00008769 Siding "4--s .-1° j'.. - '7/4/11--- 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) r 1 Owner's Name (last) / t�) (m Department Use Only 0 /�/ 1,,,,A-1(....../, � L 41 ` �. Comm 2 Project Address(not Matingrese)or Road Name Space Zip 3 CityICommuni ���� State Su siortlPlat Name -5 qgi �a�o �r 6(//‘' `� -art Ri�.S \Mac,/ \I r&cep 3/a) 4 Assessor Pa No. Lot 1 Block r7s� * * * DEPARTMENT USE ONLY * * * �J -Cl (V/ 5 Sic Code Zone Act.0 Zone Project No. 01 AG- 1 6 Dwell it No.of Buildings Sq.Ft./Acre Depth Frontage _ /3Can 7 Set Back-Front (L)S-1 (R)S-2 l Rear Census Tract Module No. Initials * 16 Architect Firm Name Street Address * Zip City State Phone ( ) Contact Person Phone If different than above ( ) Contractor F/11-m Name ) Street Address (He_ voy, AO 0-#:?_,,,I __-- (,671-12 .e&12 .----1 z.2-- i) , Zo /-t)9&ibt--(---- Zip City State Phone(5-0q ) O ) q7�� Vf�r-;17(o y04- ,Contact Person License No. Phone If different than above /10/ /fie(/a;t 4'1(0 4 ',' 31 /06- ( ) 3i;lo?r 8 Owner/Age (if different than 01 e) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check(YIN) Other(YIN) l SEPA Exempt(YIN) Date 15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ,$I Other ❑ Fire ❑ Demo ❑ Add/Alter ❑ Move r��o I b-- 14 Describe Work - --f_yy ,_ ,y ) ) --{ „,,,______, 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 #:. ';',v,vf" --e e ; 6 --z/, 00 f l, 5 = 55-, So DEPARTMENT APPROVALS This is not 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 ...• ••••• Release 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: a 11_7[11❑ Project Representative Telephone ca Agencies Performing Special Inspection: c 1 x O U = N �p 2 o as c •LL 3. 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold