1984, 11-05 Permit App: 00003202 ResidenceZ%la CIO
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your ou l to Ing plans to the Department of Building and Safety)
t Owrer'eNeeds(first)Iml
D/s /V A,,, 2 , c?'i
ppvtment Use Only
RedOpmm
2 % ssct A4En s (nOt Mellln9 AdOrwaI; Pre0 Nome
, is /c �e✓dy�
Space
Zip
�o
anlOs Mnunity
SIV c A'i
res,
I wA-
Subdivision/Plat Name
Assail NMI No.
_ �Cty-idIDA
M
Lot
Blcck
♦ ♦ ♦ DEPARTMENT USE ONLY ♦ ♦
5 SIC Ibde
S -Acta '`
/
Zone �nA PrOlect No. -2-o
'
6 Dxelll
Z
No. M Strubnpa
so.IFLIAna
CepthHo 1 +
FmntwOe� 1
7 SN Back.Frmt (L15.Bt IRIS -P
2s' I
Rwr
I
W'Iaw Trwi
...Is No.
Inniel9
JUN ro
16 Mantecl Firm Name
Street Atldrmt
Zip
On,
Slate
Mone
1 1
(post PaIDn
From, If different than above
CaltrMp Firm Name
Slrwl Md.
Zip
OIY
Slate
Poona
1 1
(bnixi Person
Josnw No.
Mo. if different than eCove
1 1
S Owner/ Agent (it different than Xt above)
Business Address
9 Zip
City
State
Phone
1 I
12 Review Required
Plan CheckV N)
Other (Yl N) SEPA
Exempt NINI
Ode
15 Type Work p BldgD
C Fire
MH
, Cemo
gINaw
Add/Aller
Replace
J Move
p
ghat
14 Dwcrlpe Work
l✓w l o✓ I v k-�
10 Appfunl Name �7
Street Address
G. /n- p B
/07 i9✓�
n zip
cuy
: A . _
state
Pnpne
Iso)
Lender
So-eet Address
Zip
Clly
Stale
Phone
( 1
(Antat PMWl
Phone if different than above
1 1
Additional Information
6) 36
93�
DEPARTMENT APPROVALS
n
Application Type
This is not a Permit
❑
unless
Indicated)
(Indicated approvals required In either 'release' or "release with conditions"
space prior to permit issuance.)
❑t
Release
Xtal
Release w/cond 1 Hold 2
ental Health
College
0
❑ Commercial; ❑ Residential
¢/ New Construction; ❑ Bldg alteration laddition
❑ Additional structure;
'(
APPLICATION M�/s.s���t/t'�����
Conditions/Com
¢
!%6�ments: 1/ r 07
❑ Commercial; ❑ Cart. of Exemption; ❑ Frontage;
N. 721 Jefferson
❑ Setbacks; ❑ lotwld; ❑ lot size; ❑ ueelzona
9� CU, variance, zone change; shoreline; ❑ fence;
Tj
❑ Oth r
Conditions / Comments:
—6 y
i
Nt J7�
F.oglorr; Y
_ v
❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson
❑ drainage E new access l approach; ❑ fence;
t
❑ road improvements
Conditio ts:
l
❑
Utilities:
N. 811 Jefferson
Condition l Comments:
❑
Other:
Plan Exam
Fire Pre,
Conditions / Com marts:
❑
Project Representative
Telephone
Agencies Performing Special Inspection:
`0
1.
E
2
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
5 U
C$ -I
G'd0-ZJ I)5Z�\ �Nn
4
cNI
r,
X11
2
0