1985, 04-11 Permit App: 00004907 Patio Cover _ 1
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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 Ownersame (last) J (first) / (m) Department Only
tpl) F�/3ci a3q. II PO&& ]` .0. f cI OA /U Jc R.. Comm
2 Project Address(not Mailing Address)ar Raid Name Space Zip
.E/.</70 .3 /</>LA Atc_ UFA9()/34L�= le.).4- 16/. 996 37
3 City/Community State Subdivision(/Pia!flame
V 2
4 Assessor Parcel No. Lot Block
JJJ��� 5 S q zj - I 1 * * * DEPARTMENT USE ONLY * * ,t
/ 5 Sic Code Zone Act.M � Zone n , Project No. ��
6 Dwell# c No.of Buildings Sq.Ft./Acre Depth Frontage
9 C' 13c>`
7 Set Back-Front 1(L)S-1 (R)S-2 Rear Census Tract Module No. Initjals) t
i *
(moi}
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
( )
Contact Person License No. Phone if different than above
( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan C eck(Y/N) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work Bldg ❑ MH ❑ yew ❑ Replace ❑ Other
14.7-/O CQ U f� ❑ Fire ❑ Demo q�Y/Add/Alter 17 Move
14 f Describef- Work
T/he;" /4 5 c CA-)C,0 -<. C.O C,£..,e)h /S— 1 K / ' '
10 Applicant Name Street Address
/4/ 711'LL0iu,u� k . � f/J/gF'r s2
11 Zip City, State Phone
%9D 3'7 ? E.i/Z4/0,9_4 E CCu/9H, ) ..24/-41oo 3
* Lender Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
V '
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.) r
❑ Fast Track
❑ /Early Start Release
Releasew/cond 1 Hold 2
Environmental Health
CI '24esidential r
5C
W.1101 College NIZI New Construction; Bldg alteration/addition •A S
Room 200 d Additional structure;
APPLICATION#
Conditions/Comments: C
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; El lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; 0 fence;
❑ Other
Conditions/Comments:
❑ Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; I
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:
ci.
❑ Project Representative Telephone
�a Agencies Performing Special Inspection:
C 1.
o O
111
H 2.
to O
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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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