1985, 01-21 Permit App: 00003979 Remodel 4
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)
1kk Owner's Name last) (f' t) �/ , / (m) I Department Use Only
\(1.40'f .LiN;Di4 6joGS/r ., / �/Y O`7 Fes. Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
7C ,2(, 3 I f--+`-
3 City/Community State __, Name
Seo kttr?� -V._,/'�} / 0o-
54- 1114
4 Assessor Parcel No. LotBlock
37S-41 t —* i r0 0` f [ * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone P Project No.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Bade-Front I(L)S-1 (R)S-2 I Rear Census Tract Module No. Initials
*
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
f C 'tv l Al- f 6k.rne7/ 5 k ym6–"4/ Soz/ff� 7Q ri A ,xi -1-'t---,c
z Citystate,A!� Phone -.9_2e, `/ 3 c 7
�l i767,2_7C57�S 0.r:Aa�5
Contact Per License No. Phone if different than above
8 Owner/Agent(if different than#1 above) 4 1 I S''8 jBusiness Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(Y/N) I SEPA Exempt(Y/N) Date
15 Type Work Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire 0 Demo Add/Alter 0 Move
14 Describe Work15.WI t l4/ 1i 1 I N\ 1-li N C, 1(
10 Applicant Name1:2t E, '�� Str A7os� &I, of 0 L+ c .._
IF ` ) ccs-
11 Zip City _ s o �� � sState Phone
yyd 7
L2e)e) 2 Z - ,36 7
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information p
20 000 A
U ""4J Win\
t. •
4 -
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; 0 lot size; 0 use/zone; •
O CU,variance,zone change;shoreline; ❑ fence;
O Other
Conditions/Comments:
Engineers: ❑ Commercial; 0 Residential; ❑ Flood Plain; I
N.811 Jefferson ❑ drainage 0 new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
El Other:
Plan Exam
Fire Prey.
Conditions/Comments:
a
❑ Project Representative Telephone
Agencies Performing Special Inspection:
cn
c 1.
O
U •-
�- 2.
a
ro c
u
3.
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold