1984, 08-03 Permit App: 00001584 AdditionBUILDING PERMIT APPLICATION WORKSHEET
, PLEASE PR;NT 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 gal (firet)/ (m)
G51 r 0 h Do LA.3kos/5 1/41$0.40res.
Department Use Only
_
Comm
r Road 2 Prgeri Address (not Mailing Address)ad Name Bdd�apeee ZIP
S6S26 IT -r27 kJE. g9a1D,.
3 OtylOemmvnity
SPot<nnE
State
WPS F{
SubdlvlslonIPla�t )Name
(% /f v/P& frIYA 4)9
4 Aaemlor Parcel No.
z551.32.' 0.3zc
Lot
Block
• * * DEPARTMENT USE ONLY * * *
5 Sic 013e
Zone ALLY
Zone
444S o6 •
- "i
Project Na. ioci
8 Dwell.*IN
1
No. of Buildl�a
Sq. FLIAcre
DepthI�� 1
Frontage � 1
7 Setp��BBS/-F/rro��n,t
(L)S-1
(R)S-2IRear
—
Oenrue Tract
Module No.
ll�h On -
r 18 MA~< 1 Firm Name Street Address
0anE
21p -
City
State
Phone
I 1
Copes Pyyn
)
Phone If different than above
Contractor Firm Name
owneOw.;1y-
Street Address
ZIp
Oty
Slate
Phone
Contact Person
License No.
Phone II different than above
1 )
e OwM1er!Aaent If different than e1 above)
SAyee 0.5 akaa J2 s* I
Business Address
9 Zip
City
State
Phone
( )
12 Refiew Required
Plan Check (Yl N)
Oth r(YIN) I SEPA Exempt(YIN)
Date
15 Ty eWork 0 Bldg
0 Fire
0 MH
❑ Demo
M❑ New
it Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
f o. &A ItekRoosn' ira.r v 1N'Raetni S Once
10 AfjplIcant Name
0DLvj\P5I5M5&VD 6-04.0 VT
Street Address �/ '1`�
a (0sa 6.. IO
11 Zig
992I2.
City
Scpok'A
State
lmNSkk
Phone -
(e°1 )- ,s ss -2.293
Lader
Street Addresee
DP
City
State
Phone
( )
Cgntact Person
Phone If different than above
1 1
Additional Information
1
a
N
N
LL
DEPARTI ENT'APPROVALS
Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
(Standard unless
otherwise Indicated)
1 fits is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit Issuance.)
❑
❑
Fast Track
Early Start
Release
Release
w/cond 1
Hold 2
W.En11101 CollegeonMl Health ❑ Commercial; ❑ Residential
W. 1101 0 New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additiona�l'
-`
�'�
rt,
^sytructure;
APPLICATION N __ 3-11(3-0
Conditions/Comments'
❑
Planning/Zoning: 0 Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone'
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments'
0
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson ❑ drainage 0 new access/approach; 0 fence;
0 road Improvements
Conditions/Comments'
❑
Utilities:
N.811 Jefferson
Conditions/Comments-
onditions/Comments❑
0
Other:
❑
Plan Exam
Fire Prev.
Conditions/Comments •
D
Project Representative Telephone
0
Agencies Performing Special Inspection:
E
o
2.
c
3.
Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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