1985, 03-20 Permit App: 00003880 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)
(last) (m) Department Use Only
1 Owner's Name/��
�rst)
ti 7 Q0Y--) Q les. !cp.
� � I
2 Project Address (not Mailing Address) or Road Name J Space Zip
3 City/Community , /
State 6'1S'ubbddivisionn/Plat
Name
r (( 1 '^
4 A Parcel No.
-Z 5.-5-.27-2_ — b.-2- 075.
Lot Lot
S
Block
—a_
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No. „ ^ e)
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bads -Front I (L)S-1
(R)S 2
Rear
Census Tract
Module No.
t Init
1
16 Architect
Firm Name
Street Address ���///
Zip
qty
State
Phone
( )
Contact
Person
Phone if different than above
( )
Contractor Firm Nr. me
`-) iL-kr-rt -SD be -a___
Street Address
6 /7 27 rYs>- 1 j
Zip Y
C72��__
City
IG S
State
(-'04
Phone
(C6`z) //V-TifiZ
Conti Person /
,)�1
License o.
S PC)X t
Phone if different than above
( )
8 Owner/Agent
(if differeri't than #1 above)y� /��
ti / / r(
Business Address
9 Zip
City
State
Phone
( )
12 Review
Required
Plan Check (Y/N)
Other (YIN)
SEPA Exempt (Y/N)
Date
15 Type
Work g Bldg
0 Fire
O MH
0 Demo
❑ New
S?/Add/Alter
❑ Replace
O Move
0 Other
14 Describe
2-1CCCCxO
Work
-- cJ a0 1.tC'
10 Applicant Name1/11,4 /
S o �/
Street Address
E /9 2-i -/-,4_,., -1
11 Zip
`1c,,2 -Q-7
City
----0.2fe _
State
(....)�
Phone
(.5-01)200 5IBV-3e'?
Lender
Street Address
Zip
City
State
Phone
( 1
Contact
Person
Phone if different than above
( )
Additional
Information (1
3!�/�r�7C/RdV� 3//05
/4/ X, --,'Ir 44,44.L. a. 4,444,07-•
Application Type
(Standard unless
otherwise Indicated)
Fast Track
/Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either 'release' or 'release with conditions"
space prior to permit Issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
O New Construction;
❑ Additional structure;
❑ Itlentlal
Bldg alteration/addition
APPLICATION N
Conditions/Comments Ki6C0S CVC r—PrN
Release
Release
w/cond 1
Hold 2
nam_ _
.1
j
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone'
O CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
0
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; ❑ fence;
0 road Improvements
Conditions /Comments'
Utilities:
N. 811 Jefferson
Conditions/Comments' -
0
Other:
Plan Exi
Fire Pre
1m
V.
iA
gas,
nam_ _
.1
j
/
_s/ --,i
/�—�g/�
Condittogs/Comments
CO
o
F-
0 E
' 0
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold