1984, 06-18 Permit App: 00000696 Remodel GQycc r_
A BUILDING PERMIT APPLICATION WORKSHEET
S 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) (first) (m) 1 partment Use Only
L G'C"T-i= J A) ff 1Z M/4))Z-r-H- Fes. Comm v/
2 Project Address(not Mailing Address)cr Road Name Space Zip
986 0 JC 714 `. '9'-cfc,
3 City/Community State Subdivision/Plat Name
5})bIr-11cpc Lufr,-
4 Assessor
�5 �1(o. — C(6�( Lot Block
LST_ * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zong Project No.
)( 6 Dweil# No.of Buildings Sq.Ft./Acre Depth Frontage
3 D to tat cszF'-
9\ 7 Set Back-Front (L)S-1 (R)S-2 I Rear Census Tract Module No. initi.
*
* 16 Architect Firm Name Street Address
APl'Lic1}0 l
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Awi-j ;...11a
Zip City I State Phone
( )
Contact Person License No. Phone If different than above
( )
8 Owner/Agent(if different than 01 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Chec (YIN) Other(YIN) SEPA Exempt(YIN) Date
eq P
15 Type Work ) Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo �4, Add/Alter ❑ Move
14 Describe Work ZtztrtO )0t_ /\9T A OP T17-i PLCY( TO Ai)t) 13/k-Tt-f -'/-'", !-10U0 (c1'rc'r-,-- /J ANy
R c/)ti L._ STiat l i2 wAy T?) ,}09 r c
10 Applicant Name Street Address
i T�r1/4'3 j-4.41 I Cir;. PA T,►t.t c_Y� S 9 S 6 4 !C 714
11 Zip City State Phone
99 2-0 SPO KA—/L)0 v., - (soy) Y2 ^2-9
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
c.40 d i t ions l Information
1 Sr Bae)
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DEPARTMENT APPROVALS Av`
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
❑ arly Start
X Release
Release w/cond 1 Hold 2
Environmental Health ID Commercial; 'Residential
W.1101 College ❑ New Construction; ldg alteration/addition
14/
Room 200 El Additional structure; 5e�`/;
APPLICATION#
Conditions/Comments: 'rw o`r ......,.....„.„0„:710/...7 �...,,
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❑ 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:
1
❑ Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage IDnew access/approach; 0 fence; I
❑ road improvements
Conditions/Comments:
El Utilities:
N.811 Jefferson
Conditions/Comments:
El
Other:
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Plan Exam 4i/q�
Fire Prey.
Conditions/Comments: longum. REMODEL
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c6 Project Representative Telephone
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ca Agencies Performing Special Inspection:
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T 70
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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