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1984, 10-01 Permit App: 00002576 Reroof 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 p(last) f(ffiirst) (m) Department Use Only Polo k3 ihhEc. I I Res. Comm 2 Project Address(not Mailing Address)or Road Name Space Zip E. 10117 !dam alki �pe6,-re- Wi9- 11.z05 3 City/Community State Subdivision/Plat Name _1 041‹ c3-Cr; O , c7 6''� l.Of t' \ Li PoKz�"C_____ VIA 4t /CA..cl tJ��-u�' n,ii-e-(Z,1",/,/ PL6tc 4 Assessor Parcel No. e Lot I Block q ^ 3/ q 161-144J- 1/11 ©.t.y �j * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act.# (Zone Project No. 6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage 7 Set Back-Front I(L)S-1 (R)S-2 'Rear Census Tract Module No. Initials * 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 Check(YIN) Other(YIN) SEPA Exempt(YIN) Date 15 Type Work ❑ Bldg 0 MH ❑ New ❑ Replace ❑ Other ❑ Fire ❑ Demo ❑ Add/Alter ❑ Move 14 Describe Work 4190F1 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 4X? UW/1%411 ON) = 0 2S-Zi 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 w/cond 1 Hold 2 Environmental Health ❑ Commercial; ❑ Residential W.1101 College ❑ New Construction; ❑ Bidg 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: El Utilities: N.811 Jefferson Conditions/Comments: Other: Plan Exam Fire Prey. Conditions/Comments: a. c c_J ° Project Representative �' Telephone a Agencies Performing Special Inspection: c 1. . O lfl f0 V. E 2 y o LL c 3. 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold