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1984, 11-28 Permit App: 00003540 Addition a BUILDING PERMIT APPLICATION WORKSHEET e 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's Name /. (last) (m) IR..Q3partment Use Only C� /UJ ,- .'` iA/� Comm 2 Project Address(not Mailing Address)ar Road Name J Space Zip . -----/5-3 a 3 / z t L 3 City/Community State /4._ Subdivision/Plat Name 4 Assessor Parcel No. Lot Block Z�JS`-/y-- c3',0 Z' — * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act.# 'Zone knv l Project No. ..0) .„,_ . 6 Dwell fft No.of Buildings Sq.Ft./Acre Depth O©1 ^} Frontage 3 ` 7 Set Back-F�� I(L)S-1 (RS-2 I Rear Census Tract ( Module No. Initials * * 16 Architect Firm Name Street Address Zip 7 City State Phone / Contact Personr/ Phone if different than above o ( ) Contractor Firm Name Street Address ..-----7,� i,_ 7 oS/s , /�— s 1i00S V- -- 3 7 lif Zip City State Phone Contactwwn d License No. Phone if different than above � -,. �, ,,•- KI c 4 z-41 ow ( ) 8 Owner/Agent(if different than#1 above) k / '1.7/ j Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check(YIN) Other(YIN) SEPA Exempt(Y/N) Date 15 Type Work ❑ Bldg ❑ MH 0 New 0 Replace 0 Other 0 Fire 0 Demo Q" AdNedlAlter 0 Move 14 Describe Work P-2-1 Iz 5u os 'Pr APO - 10 Applicant Name Street Address 11 Zip City State Phone ( ) * * Lender Street Address Zip City State Phone ( ) 3. Contact Person Phone if different than above ( ) Additional Information vop 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 ❑ Early Start Release Release /cond 1 Hold 2 ❑ J Environmental Health ❑ Commercial; ❑ Residential %all• W.1101 College ❑ New Construction; ❑ Bldg alteration/addition Room 200 ❑ Additional structure; AP-Ll •TION# e • Conditions/Comments: `' kAAJL V MV In ❑ Planning/Zoning: El Commercial; ❑ Cert.of Exemption; ❑ Frontage; N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; ❑ CU,variance,zone change;shoreline; ❑ fence; El 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: coa �'❑ Project Representative Telephone ma Agencies Performing Special Inspection: cn 1. o o U ~• E 2. h U • c 3. 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold