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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