1985, 05-24 Permit App: 00005598 Addition, Garage P
a
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) (first) (m) I Department Use9(ily
t
Res. J Comm
2 Project Address(not Mailing Address)cr Road a Space Zip
t 1111601a A ys zo k
3 City/ muni) State Subdivision/Plat Name
4 Assessor-=rcel No. Lot Block . . * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone ���1 Project No. 669g
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
I I . 2S ISLS 85-
7 Set Back-Front I(L)S-1 (R)S-2 l Rear Census Tract I Module No. Initi s
ES-157/ NI.a• it
* 16 Architect Firm Name Street Address
Zip City 'State Phone
( )
Contact Person Phone if different than above
( )
Contra Firm–NDe – ///� Street Address
410.01 VII agt-4.44.4.6m±
Zip City State Phone IV_922
`9020-7 -��f° 2v4.... ( 9z.14-V3V3
Con Person License No. Phone If different than above
i c+- OA3EcxL wG /SAF ON ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) [SEPA Exempt(Y/N) Date
15 Type Work LA/Bldg 0 MH ❑ New 0 Replace ❑ Other
QQ ❑ Fire El Demo �Add/Alter ❑ Move
14 De ibeWork /P xPZ—
Ils ic%ArCei A-00, a_4RA-�rE 576, 51
10 Applicant Name Street Address
11 Zip City State Phone
( )
* Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
I
Additional Information
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
R:lease w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential /cel
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure; I,, ;•d.; i
APPLICATION# A /3 /7Y
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:
Plan Exam
Fire Prey.
Conditions/Comments:
coa
°❑ Project Representative Telephone
a. Agencies Performing Special Inspection:
1.
Y O
U '-
E 2.
o
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LL
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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