1984, 12-21 Permit App: 00003763 Residence a, ` J4, Vol: V'_BUILDING PERMIT APPLICATION WORKSHEET
'PLEASE PRINT AND COMPLETE ONtY 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 me (last)_ (first) (m) f Department Use Only
r�U/i�6 %/( i Ras. Comm
2 Project Address(not /—.5 Address) r /Name—7� Space Zip
3 City/Community State Subdivision/P at Name /
S �l 6kJ
4 Assessor Parcel No. , 1 C] 3 Lot B
2– .3S -3 � ` JC
* * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.0 Zone Project No. /
.% „7.7 f-
6 Dwell 0 No.of Buildings Sq.Ft./Acre Depth t Frontage
1 j l3c 105
7 Set Baric-Front. (L)S-1 t (R)S-2 c Rear Census Tract Module No. Initials
* 16 Archil Firm Nam (2774).2
7 I Street Address
S
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor F a ///ILS / / Street Add(re/ss `_
Zip e
/ G�; oe-1 r/ �A���2tatn Phos( < ) 9-7,3-75--o
Cont Person c �� L���` f T Phone if different than above
!f/ 1
8 Owner/A t(if different than 01 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(YIN) SEPA Exempt(Y/N) Date
15 Type Work Bldg ❑ MH L3,-,6 ❑ Replace 0 Other
0 Fire 0 Demo 0 Add/Alter 0 Move "V/
14 Describe Work
YeSfWeAfce,- 6-fi-0C c( Cie`aye
10 Applican Street Address
7"4/..5
11 Zip City State Phone
( )
* LenderStreet Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
MF .- t593 /
, pg, - i 6
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.)
❑ Fast Track
❑ Early Start Release
Release w/cond 1 Hold 2
EI Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition (/ 4
Room 200 ❑ Additional structure; (//�v
APPLICATION# l / 3SD / /// y
Conditions/Comments: /
❑ Planning/Zoning: ❑ Commercial; O Cert.of Exemption; ❑ Frontage;
N.721 Jefferson El Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; rt
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements /7--71(#17
r
Conditions/Comments: ` (,
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ Plan Exam ,2 7y
Fire Prey.
(Z
Conditions/Comments:
a
cas_I
Project Representative Telephone
Agencies Performing Special Inspection:
O c 1.c (O
F- E
2.
co
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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