1985, 02-14 Permit App: 00004181 Residence 3 71 -
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 Name a____yucvize(lQast�� (first) (m) t7epartmentUse Only
�" . Fbs.
2 Project Addr (not Mailing Address); -. d, Space Zip Comm
• /f ( /S.Sot.
.
3 City/Community�//��j6 / State Subdlv (Plat am ./7Qt
itink -
4 Assessor PaSScefNo. 6/C LotBlock
7 I * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.ff Zone Project No. "-) 1 e
6 Dwell4 No.of Buildings ' Sq.Ft./Acre Depth I Frontage
C 08 '
7 Set Back-Front (L)S-1 (R)S-2 t Rear Census Tract Module No. Initials
1 2-41`I 2-1 — f 0 N M
30
* 16 Architect Firm Name Street Address *
Zip�} J q20(-/
20 Gty��a / State Phone
�' , y l 604 -2y2 -7 7g-7
Contact Person ' Phone if different than above
0--e-i-dla :-
jf
Contractor Firm Name Street Address
. 'Cl----7--)1.._Q___
Zip City State Phone
( )
Contact Person Lice o. _ Phone if different than above
40/a"77 5e7/M- ( ) S
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(Y/N) Date
15 Type Work Bldg ❑ MH New ❑ Replace 0 Other
❑ Fire 0 Demo 0 Add/Alter 0 Move
14 Describe Work �j� _� Q
726,::::2
L.��-rte v'.'c--'G� -
10 Applicant Name G � Street Address
11 Zip City State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information j
1F - 1 D 8 I YI
::-=s \
' F -- 147_ r. - \ ,
,
•
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
❑ 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; 0 use/zone; ,
0 CU,variance,zone change;shoreline; 0 fence;
0 Other
Conditions/Comments:
❑ '`w
Engineers: ❑ Commercial; ❑ Residential; 0 Flood Plain;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments: /-/VA—O`3
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
•
❑ Plan Exam
Fire Prey.
Conditions/Comments:
a
❑ Project Representative Telephone
Cl), Agencies Performing Special Inspection:
O c 1.
CI as
2.
h O
c
LL
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
"R. •
-{ 7 3/0c k Addit
59 I oy 11/
/1//, 5.5c.,_
cc)
aez
• 1
svg/
zLf
o _
o
ih‘o
ag.