1984, 06-28 Permit App 00000927 AdditionBUILDING 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 '
er's N e �_
(last) (first) (m)
Cepartment l/�pe Only
Fes.
Comm
Comm
2 Pf0lect d (not fling Address or oad (�am� Space Zip 9 fe
3 I !Community
5t jl
Subdivisigg) PlatName �� "NO
4 Assessor Parcel No.
4 kSSZ- 1 W7
I
Lot
—7
Block
I �L
�(
* * * DEPARTMENT USE ONLY * * *
5 Slc Code
Zone Act.1S
Zone .....R44
roject tsic t
���
6 Dwell #
A
' l
No. of Buildings
• Sq. Ft./Acre
Deptl
Frontage
7 Set Back -Front
1 (L)S-1
(R)S-2
[Rear
Census Tract
I Module No.
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Na
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check (YIN)
Nr
Other (ylN)
I SEPA Exem (YIN)
Date
15 Type Work ❑
0
Bldg
Fire
❑ MH
0 Demo
❑ New
y Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work ')_ ADD o/4
Aed liZe ' eh. )Oe` M. }4. (Atc(j) x r
)
10 App . nt NanSe
`
Street Address
11 Zip
qqp (
City I
Stay
1, -.,k ,
Phone
(: 1) M 75 g
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
r
7 X i 14S O
- C'e. ,lad Aite ED W T ?ti r V- 84
4-
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a 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;
V esidential
Bldg alteration/addition
APPLICATION #
ele1
Release
w/cond 1
Hold 2
Conditions/Comments
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions / Comments•
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage ❑ new access/approach;
0 road improvements
Conditions/Comments
❑ Flood Plain;
❑ fence;
Utilities:
N.811 Jefferson
Conditions/Comments
Other:
PI
FI
m Exam
e Prev.
(/��
ter
111{fflyyy
Conditions/Comments
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold