1984, 09-10 Permit App: 00002185 Residence ` 6%
BUILDING PERMIT APPLICATION WORKSHEET 121
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU U TAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name / (last) �, (first) (m) Department Use Only
FI S 6orcacSk Yf Res. Comm
2 Project Address(not Mailing Address)ar Road Name Space Zip
l / 311 231: /a/Z°
3 City/Community State Su ivision/Plat Name
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4 r Parcel No. Lot Block
26 S4
3 — ir/i� 1-5
. I 7V * * * DEPARTMENT USE ONLY * * *
5 Sic Code`} Zone Act.# Zone✓ Project SFyNo. �' ��j
6 Dwell# No.of Buildings Sq.Ft./Acre Depth i Frontage
7 Set Back-Frontl I(L)S.1 (R)S-2(7 ) 'Rear Census Tract Module No. Initials��f'L0� Iy - J o N no ,
* Street Address *
16 Architect Firm Name
Pie r ch.. - e -le /c
Zip Ci n State
Phone
g�llT L h e re. ( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
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W
Zip City 1 State Phone
1VO4i sp,/(gh. 4)At– ) T2‘- 70',0
Contact Person License No. PhoneIf different than above
Fl 1\1 C'AtIR- F ( )1 I .12e- 577 2.,.
8 Owner/Agent(if different than#1 above) )p f I $'f Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
Street Address
Lender
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
rn r = 10 0
U = i 3 0
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1 1
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 Release
Release w/cond 1 Hold 2
"chi Environmental Health ❑ Commercial; El Residential
W.1101 College El New Construction; El Bldg alteration/addition
Room 200 El Additional structure;7V--/e)67
APPLICATION#, O V/U6/q
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Conditions/Comments: �. - -"-J--71--
-- -- /-1.4---- I
CI Planning/Zoning: ❑ Commercial; El Cert.of Exemption; ❑ Frontage;
N.721 Jefferson El Setbacks; El lot w/d; El lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
CO Engineers: El Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson El drainage ❑ new access/approach; 0 fence;
❑ road improvements /
Conditions/Comments: /909 — c--/7
❑ Utilities: --
N.811 Jefferson
Conditions/Comments:
❑ Other: _—
111 Plan Exam '// /.
Fire Prey. r,
Conditions/Comments:
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To Project Representative
Telephone
(DI Agencies Performing Special Inspection:
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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