1984, 07-30 Permit App: 00001466 Pool i • _
•
BUILDING PERMIT APPLICATION WORKSHEET
PLEASEIMST AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
'saw return this original and your building plane to the Department of Building and Safety)
1 Owner's tPeet) (first) (on) IOlarawe Use Only
k-.2( CX7.4/S el,L/ /9/f/L Li/la Comm
1 Priacl AddeeipOI P late Aaelsa)or Roel Space Zip
t i.3zoy /'0 � ,u6
3 Oty/Coe 1ty State SuWIvlsiMl Plat Name
$�/Gfie(JC 6/.41--
4
./y//a Memo. Ne. Lot Block
2 7- /(
o
3 2 / . w . DEPARTMENT USE ONLY * *
5 SkJ Ofde -AveAvehati Zone Project No. IA(
6 Oae111 No.of Buildings Sq.F1.lAw Depth Frontage
1 1 Rear
Cisme
7 SN aed.Front R3 �1 i (R)� l �IJJ M .1 Tract Module No. Initials
. .$1
* 16 AMMON Fine Nan. I Street Address *
Zip City State Phone
( I
Contact Person Phwe If different than above
1 )
7:2ab Fins Name Street Address
/ ‘6�2L — "e E ras'?tf cic-i.zree,iftee
Zip City State, Phone
% g2-7(o �2 cr ae2q- (5 c/) 9z,--1 las—
5; t License No. Phone if different than above
-;;;P..007(1JJJ6 t'tSo%-' 2-23 -c/ int-tui 14/e7a ( )
e Owner)Agent(if differs*than et above) Business Address
9 Zip City Stab Phone
12 ibvIew Required Plan Geek lY/N) Other(Y/N) I SEPA Exempt CY/N) Date
15 Type w rk :1 Bldg C MH C New C Replace ,H..0 011ier
0 Fire C Demo C Add/Alter 0 Move P44(A c'l t
14 Describe Work
52N
14
10 Applicant Name D // 'Street Address
11 Zip City0State Phone
( )
•
Lender Street Address a
Zip City State Phone
1 1
Contact Person Phone If different than above
Additional information
/ZI-
•
•
gip,
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.)
❑ Fast Track •
0 Early Start I Release
�✓ Release/ewlcond 1 j Hold 2
Environmental Health ❑ Commercial; ❑ Residential /'av V'( I
W.1101 College C New Construction; ❑ Bldg alteration/addition I
Room 200 ❑ Additional structure;
APPLICATION N K..:24"--C-)9-Dir
Conditions/Comments: U
❑ Planning/Zoning: ❑ Commercial; C Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot wid; ❑ 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 Prev.
Conditions/Comments:
CO
to Project Representative Telephone
a. Agencies Performing Special Inspection:
1.
2 17,
F E
2.
E
3.
1 indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold