1984, 07-25 Permit App: 00001368 Residence 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 �( (last) (first) (m) Department y se Only
Wec. d /d
Ss, ct eft Ji,7C . Fes. Comm
2 Project Address(not Mailing Address)a Road Name Space Zip
,' 9 2-V L: .97 ?.
3 Clty/Community State Subdivision/Plat Name/ / / j�ah
/�
•
4 GPa 2el N e Lot ��a„ Block C ( 7F4,'i C/C� /../'X �7 V tZ a�
..34-2--— l CJ t / f it * ,t DEPARTMENT USE ONLY * * ,t
-23
5 Sic Code Zone Act.# Zone Project No.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
1 1 tzs tzs`
7 Set Bads-Front (L)S-1 (R)S-2 i IRear Census Tract Module No. Initials
35 t o r9�-4-
16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address� /
le S 4 cSC CCIZ FS', 7 c - 0`/ , £ ?c NO (,
Zip City State Phone
792-/V Siou K,-,,,,,, (c).e� (S07 ) 9-2-/ - ,/
Contact Person License No. PhoneIf different than above
4// cm>' 7 -/1` C7> -SA-SI- 2-4L JF. ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) I SEPA Exempt(YIN) Date
15 Type Work ❑ Bldg ❑ MH New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
Si )1q/ c-1 ; ( _, t. weft;.41/
10 Applicant/Naaame( // Street Ad resits Q / /
L-C7, iC :1 , i� AScC,,c; aTF., T�'1C. P\ ee, f,,/op,/
11 Zip City State Phone
c 2. V Sa c .. ( 5C,9 ) 9 yfsl
��
Lender // Str t Address
Cr'>///et kit /� 2 cR'L f//C ;• Iti, 3/0 (1),-9c-,,,,...._ ed.
'
Zip City State Phone
r.
9-9 `7-c• � or kgin.: «?` ( ) 72z--- (2C'ci)
Contact Person //� Phone if different than above
A.
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.)
❑ Fast Track I
❑ Early Start Release
CJ Release w/cond 1 Hold 2
J Environmental Health ❑ ,Commercial; iP4lesidential z-�/?(',
W.1101 College New Construction; ❑ Bldg alteration/addition .
Room 200 ❑ Additional structure;
�
�/ �
APPLICATION# Ai-ay/7
T
Conditions/Comments: 7A /1)-
7--__":"
0 Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
0 CU,variance,zone change;shoreline; 0 fence;
0 Other
Conditions/Comments:
�f t/
L
Engineers: ❑ Commercial; 0 Flood Plain;N.811 Jefferson ❑ drainage f�new access/approach; ❑ fence; I )ifiyi
I
0 r:d ipprovemen . - •
Conditions/Commen -..... a 1 ` Y`- . �-, - -__12— A.-:2-1_,
Ce.a.a- te" / i
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
El
Other:
•
fil Plan Exam ,- ,1�/
Fire Prey. t,
Conditions/Comments:
a
co
c-J
0, Project Representative Telephone
cn Agencies Performing Special Inspection:
1.. O
c 1.
U '-
I- E 2.
y O
N c
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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