1984, 05-09 Permit App: 00001375 Residence 5`i 1 l (0 . 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) Lcj-4'
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1 Owner's Name '���i(last) (first) (m) JmtoniY
SFc t./E 4� l 1 t`frft Fps. Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
E.%Z4•z1 1(114 q92. ..
3 City/Community State Subdivision/Plat Name
_CPO ��-`•- LL- Ht S h S#p-- Z. `-LL o✓1,-f- .4it o P40
4 Assessor Parcel No. Lot Block 8
.2. L S ,7 — K�/L og?g-0831 . t . DEPARTMENT USE ONLY * * *
5 Sic Code `�J Zone Act.# Zone Project No.
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•:N 6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ l y 2 8'b // q
7 Set t, I(L)5.-1 , (R)S-2 ( Rear Census Tract Module�No. ials_
30 410 -�/�'tt LO e7:-.)
* 16 Architect Firm Name *
Street Address
Zip City State Phone
Contact Persaa-----'--- Phone if different than above
( )
Contractor Firm Name /? Street Address
Zip City State Phone
( )
Contact Person License No. Phone if different than above
ST�V� 14-� Z ( )
8 Owner/Agent(if difi
ent than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required an Check(Y/N) Other /N) SEPA Exempt(Y/N) Date
15 Type Work /Bldg ❑ MH New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
Sf C/E t A-41 / //ff 6•,--t-7//,'-‘ G
10 Applicant Name Street Address _
/9._
00(-1 6 / /7 i .1 " / 77-5
11 ZipCity Phone
./ / C . 7 L/6 2 I/1dii-� State 6t. it/1 ( ) q2e- i/(y/
* Lender Street Address
Zip St Phone
—mac' ( )
Contact Person Phone if different than above
( )
Additional Information
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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.)
0 Fast Track
0 Early Start Release
Release w/cond 1 Hold 2
Environmental Health
1;4 (.6ommercial; .1
W.1101 College. , New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
APPLICATION#
Conditions/Comments:
0 Planning/Zoning: 0 Commercial; O Cert.of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; O use/zone; .
O CU,variance,zone change;shoreline; 0 fence;
O Other
Conditions/Comments:
Engineers: O Commercial; 0_,fit4E1/ idential; 0 Flood Plainj65-#
N.811 Jefferson 0 drainage new access/approach; O fence;
O road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
Project Representative Telephone
0. Agencies Performing Special Inspection:
1.
E
2.
co 0
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U_
3.
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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