1984, 08-22 Permit App: 00001885 MH y
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'sl� NameL (las (first (m) Department Use Only
/""�h�1 7� U o ua vi t RIM• Comm
2 Project Address(not ailing Address)or Road Name Space Zip
X500 E lea A cQzd6
3 Citëjôkne
munityState Subdivision Name
Name
4 el OnS Sud
4 Assessor Parcel N . Lot Block
265.111#i . —fee / / * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone 'Project No. )813,;-
a66
Dwell# No.of Buildings , Sq.Ft./Acre Depth Frontage
/ 03 /d6
7 Set Back-Front (L)S-1 (R)S-2. 1 Rear Census Tract Module No. Initials
* HCl 5 3 L ��
16 Architect Firm Name (Street Address *
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor i�NaStreet Address
Pe Dm es N/ 53/5 Lort,rar,
State Phone
Zip
p�iga2 7 Gs Cithr1Jj Ce/& (50�) Q28 -/VV'/2
ntact Person License No. PhoneIf different than above
Leh e Zahc) R?geuts 4'33/q 6 ( )
8 Owner/Agent(if different than#1 above) Business Address
P s
9 Zip City State Phone
( )
12 Review Required PlanCheck(Y/N) Other(YIN) 1SEPA Exempt(YIN) Date
15 Type Work B4 Bidg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe W
ori See-lion o2oc/Q/ar /16m9
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
u6 _ 45YI4it- -3) = LFA} '
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j ( i ic- i1
Application Type
DEPARTMENT APPROVALS
This is not a Permit
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
ID Fast Track Release
❑ Early Start01
(Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential > r
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition 4
Room 200 ❑ Additional structure;
APPLICATION# g`T -o q 7 47 AA
.tiv
Conditions/Comments: ��6''v �
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
O Other
Conditions/Comments:
$/
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; 40Lir I
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence; illi 1
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
❑ Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
a
rn
c❑
.° Project Representative Telephone
a Agencies Performing Special Inspection:
cn
1.
Y O
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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
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