1984, 12-10 Permit App: 00003653 Addition 4 .
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 1 Owe= ' _ • (last) (first) (m) Department Use Only
_ � �zRes. Comm
j 2 Project Address(not Mailing Address)or R d Name / Space Zip
/--. / 9/ ., v."4 (i''-
37/Community State Subdivision/Plat Name
4 r Parcel No. LotBlock
5Y 4 r —6 20/ i ** * DEPARTMENT USE ONLY * ,t *
5 Sic Code Zone Act.# Zone T - Project No.
6 Dwell# No.of Buildings K Sq.Ft./Acre Depth Frontage
l I LVAIF---ecO
7 Sett BBCensus Back-Front 1(L)S-1 ( (R)S-2 I Rear CeTract I 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
/,�,--�mss'l a - � 61 / 7 A). 7' (:i,.,/_,-1_,, 1 ,
/ Zip / City State Phone
/a
Contact Person License No. Phone if different than above
II7a-Al&QC_ %�JCBei ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) 1SEPA Exempt(YIN) Date
15 Type Work Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo y Add/Alter I Move
14 Describe Work ^ 'S1 O mp
rro t•1
10 Applicant Name I(/_'✓ Street Address
11 Zip City State Phone
} ( )
* *
Lender Street Address
Zip City State „ Phone
( )
Contact Person Phone if different than above
( )
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.)
fl Fast Track
Early Start Release
Release w/cond 1 Hold 2
Environmental Health 0 Commercial; 0 Residential
W.1101 College D New Construction; 0 Bldg alteration/addition
Room 200 D Additional structure;
APPLICATION#
Conditions/Comments:
Eli Planning/Zoning: U Commercial; 0 Cert.of Exemption; CI Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
• CU,variance,zone change;shoreline; 0 fence;
O Other
Conditions/Comments:
111 Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage U new access/approach; 0 fence;
O road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
111 Plan Exam
Fire Prey.
Conditions/Comments:
0.
. ,
Project Representative Telephone
c.)
a)
o. Agencies Performing Special Inspection:
CI)l c
1Q• Z .
0
2.
o
la c
U-
3.
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Oil