1985, 04-24 Permit App: 00005096 Addition 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 Na - (last) '1 (first) c l e (m) ( partment,
�/SeOnly
#fes- - d�-Aek- C- RasComm
2 Project Address(not Mailing Address)a Road Name (f Space Zip
//J' 6 ) ,. 'x714
3 City/Communit State Subdivision/ lat Name _�
�0 N-' /w�- A ecHC /OCOAr S 1718
4 Assessor Parcell No. +� Lot Block
�5 i �5 — 332_2-
S * * * DEPARTMENT USE ONLY
Sic Code Zone Act.# Zon Project No.
Sue 50(16
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Back-Front/ I(L)S-1 (R)S-2 I Rear Census Tract I Module No. 1 Initials
EXf 5T
/A!G- (74',-,4
* 16 Architect Firm Name Street AddressI *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
( )
Contact Person License No. Phone If different than above
( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(YIN) SEPA Exempt(YIN) Date
15 Type Work ❑ Bldg ❑ MH [ New ❑ Replace 0 Other
❑ Fire ❑ Demo Add/Alter ❑ Move
14 Describe Work _
2- y /- /1-cid To WeS/c/e ret
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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6 rr1°ady Clo A.,S"Ivy e led
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.) r
Fast Track
Early Start Release
Release w/cond 1 Hold 2
O Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
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:
a
•o❑ Project Representative Telephone
0. Agencies Performing Special Inspection:
c 1.
O
U '-
ro
►- E 2
n' o
LL
c
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold