1985, 02-04 Permit App: 00004093 Residence BUILDING PERMIT APPLICATION WORKSHEET x..2
' 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) f Department Use Only
LA: t ig_S q A5�0C / AC-G C... f li3s. Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
'- ,--Air--a*gv /Y Yo 8' e' /6 771. 9 .2(9g
3 City/Community State Subdivision/Plat Name
S PCKPI,Ce_ Z 6/A.,' _ 5'c a r-i/ A0rws i947,0.ci
4 Assessor Parcel No. Lot Block
2-6;4i — Z(OO 2 * . * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No. J
.locy
6 Dwell# No.of Buildings Sq.Ft./Acre Depth i Frontage t
I I 12,C 103 ._Th
7 Set Back-Front 1(L)S-1 , (R)S-2 I' l Rear Census Tract Module No. Initialp
o ' Zo 1 .. , ti
I jY) ,
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
.t;. 2_ S ,4- fEsc-(-7-. i4 C _ L' e• k l lc �tl
Zip City 1 State Phone
902—/li grr. i4 a't,/ ( s-a? ) 7y— eco,
Coact Person License No. Phone If different than above
> is ( Srti/771 I R.. A 5 H 6 ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) 1SEPA Exempt(YIN) Date
15 Type Work f - ldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
-5,it64E 1;9 ACior—e-cF eyDe4E_ 4-7779c,hei �/-/ ',"-e-e:
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 Informa ion , s
F= 1322 - 313v
u 13o fi „ , ' �; 2
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
12/'
Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
O
APPLICATION# 5-
Conditions/Comments:
Conditions/Comments: t Vega.
O 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: El
ElResidential; ❑ Flood Plain; -
N.811 Jefferson ❑ drainage 171 new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
I
Utilities:
N.811 Jefferson
Conditions/Comments:
CI
Other: L
0 Plan Exam
Fire Prey.
a-S /5''S
Conditions/Comments:
ci.
c❑
0—° Project Representative Telephone
ca Agencies Performing Special Inspection:
O c 1.
U '-
e N
E 2
m 0
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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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