1985, 04-08 Permit App: 00004833 Siding 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's Name (last) (fir ) (m) r Department Ude Only
ies( f I9s. / Comm
2 Project Address(not Mailing Ad s)or Name f kt Space Zip
• /
3 City/Co unity /,,Q617 l� State Subdiv1 ' latt Name A
OMIle Lot Block If �r 0 E-/rS *f cf
4 Parcel No. ,
t L�j5AL3 F //�e 3 , / * * * DEPARTMENT USE ONLY * * *
5 Sic Code /Zone Act.# Zone �L� Project No.
6 Dwell N No.of Buildings Sq.Ft./Acre Depth Frontage g
5 ) --,
_
/5
at)
7 Set Back-Front. 1(L)S-1 (R)S-2 1 Rear Census Tract Module No. Initials
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Cont or Firm Nam Street Address
CfO �jrd fGrQr LOOkar �r5 t 72 , /¢ (),f
Zip Ord*?
State Phone
Con son License No. Phone If different than above
8 ner/Agent(if di ferent than#1 Lye) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace �f Othgy.
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move /` J
14 Describe Work
T��� sd/0y ) rase /A--
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
ji?Ant i .40}o, ; I 11761)
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.) r
Fast Track
Early Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ 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:
O Plan Exam
Fire Prey.
Conditions/Comments:
c
Project Representative Telephone
a Agencies Performing Special Inspection:
c 1.
O
U
os
H E 2.
�, O
Oc
LL
3.
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold