1985, 05-16 Permit App: 00005460 Residence 7(00 r 30 1 aC
' 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)
L
1 Owner's Name (last) (first (m) I Department Use Only
df/le,p,P ! ,j (.2 ,Jc 0, f Ft 3a. Comm
2 Project A ress(not Mailing Address)a Road ame Space Zip
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3 City/Comm nity State Subdivisi Plat Name �
J �,®.ti� ,.a `. r
,Y.4' ./4 Assessor Parcel No. 3C0v ` Lot ( Bloc/ * * * DEPARTMENT USE ONLY * * *
5 SicCode Zone Act.# Zoneo.
AFP 54,
6 Dwell# No.of Buildings Sq.Ft./Acre Depth 1 Frontage
I Z )
7 Set Back-Front
1(L)S-1 (R)S-2 i Rear Census Tract Module No. Init' Is
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip/ f GJ, -7e I State Phone
Zip
J ' o ,r�,,i� ,/ ( ) u 7
Contact Person License No. Phone if different than above
5/6rrt/ ,'",19 � ( ) , ��-o2 9/ -.2_-
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) I SEPA Exempt(Y/N) Date
15 Type Work ,- Bldg ❑ MH 7.,New 0 Replace ❑ Other
0 Fire 0 Demo 0 Add/Alter ❑ Move
14 Describe Work VI
G 2
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
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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 ReleaseReleJ'/ w/cond 1 r Hold 2
�+ J Environmental Health 1=1 Commercial; ❑ Residential /6),, LA/
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition �j�/X
Room 200 ❑ Additional structure;
APPLICATION# 0 L'4/97
Conditions/Comments:
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; El lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; C
. N.811 Jefferson ❑ drainage ❑ new access/approach; 0 fence;
❑ road improvements
Conditions/Comments: L ry & , - / _ Lam, s s . m i s_`.� QE
I� _Q� O AA. S =s (.c 4P Q,lNl^e -- -
Utilities:
N.811 Jefferson
Conditions!Comments:
El
Other:
El Plan Exam
Fire Prey.
Conditions/Comments:
a
c❑
Project Representative Telephone
cc. Agencies Performing Special Inspection:
c 1.
. O
0 —f0 �p
E 2
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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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