1985, 06-21 Permit App: 00006065 Residence ,r
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'sJName . (I t) (first) (m) rpartment Use Only
K�Y1 L r
/ 7/J € . Comm
2 Project Address(not Mailing Address)ar Road Name Space Zip
. 12-O O6 54eA,i� i-
3 City/Community State Subdivision/Plat Name
S�GiraYle (A-//q U/v/UF'$fTV l Gn-- -
4 Assessor Parcel No. Lot Z Block
2^ C�/c/ — /95 / Q 2O4Q' /�j . , t DEPARTMENT USE ONLY * * *
I1 ,J`7`f / 7 7 ( Q (�
5 Sic Code Zone Act.# Zone ���� � Project No. C/°6'
6 Dwell# No.of Buildings Sq.Ft./Acre Depth f Frontage
1 (� .75
7 Set Back-Front t I(L)S-1 � (R)S-2I
Rear�I Census Tract I Module No. Initials �/��
30glaZ h' 8 „-.I (I(Q V ► 1
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contr Firm Street Add
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Zi Ciry, State Phone
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Contact Person License No. Phone if different than above
Yil c 1eLk K-Wit!-x -as 6 `D---(0 ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work Bldg ❑ MH 3K New ❑ Replace ❑ Other
❑ Fire 0 Demo 0 Add/Alter 0 Move
14 Describe Work
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
Yh F = ( f
U _ 0 64 2;
DEPARTMENT APPROVALS 4.
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.)
r
❑ Fast Track
fl Early Start Release
Release w/cond 1 Hold 2
"" Environmental Health E. Commercial; El Residential
W.1101 College `X New Construction; ❑ Bldg alteration/addition
Room 200 El Additional structure;
APPLICATION# ‘ , `� 72 7
Conditions/Comments: �.--c� b C� L77
0 Planning/Zoning: El Commercial; El Cert.of Exemption; ❑ Frontage; _J J
N.721 Jefferson El Setbacks; ❑ lot w/d; El lot size; ❑ use/zone;
El CU,variance,zone change;shoreline; El fence;
El Other
Conditions/Comments:
i V't-1 Ri Engineers: 111Commercial; ElResidential; 111Flood Plain;
N.811 Jefferson El drainage new access/approach; 0 fence;
❑ road improvements
Conditions/Comments: �/,�4- 7fc ,
El Utilities:
N.811 Jefferson
Conditions/Comments:
O Other:
T--- if j
E Plan Exam / '
Fire Prey.
Conditions/Comments:
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❑ Project Representative Telephone
a Agencies Performing Special Inspection:
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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