1984, 08-27 Permit App 00001948 Residence0�
BUILDING PERMIT APPLICATION WORKoSHMEET
o UNDERSTAND
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS
(Please return this original and your building plans to the Department of Building and Safety)
Only
2
3 City/Community
4 Assessor
a
5 Sic Code
6 Dwell M
7 Set Back -Front
16 Archit irm Name
Zip
Contact Den
Protect Address (not Mailing Address) or
. ld24Z
K
•
t7
Contractor irm Name
T A te}ov r.e S
Name
w�
No. of Buildings
(R)S-2
—10
%1A1+tonw
City
k-kiervetc.1•S
Zip
son
O►1r
City
8 Owner/Agent (if different than #1 above)
9 Zip
City
State
Rear
Spacelar /1 9 �
' Subdivision/ Plat Name
Tit
State
State
41c
Comm
Zip
If av
* * * DEPARTMENT USE ONLY * * *
Project No.
Street Address
Phone
( )
Phone If different than above
48
Frontage
14,01
lalke
Street Address ` NE 5
•
License No. C IF 203
03 (ILO
Cali Business Address
Phone
(
12 Review Required
Plan Check (Y!N)
15 Type Work
,13Idg
❑ Fire
State
Other (YIN)
E MH
D Demo
Ne
��❑
) 41243 • 2-et4Z.
Phone If different than above
( )
I Phone
SEPA Exem t (YIN)
w
I
❑ Add/Alter
14 Describe Work
aE� ( NtJe
10 Applicant Name
n Replace
❑ Move
Date
❑ Other
11 Zip
l City
Lender
Zip
Contact Person
City
Additional Information
MF lQai�'
<3 n-
ur3
State
State
Street Address
Phone
IStreet Address
Phone
Phone If different than above
`OQ.
❑ Project Representative
Release
w/cond 1
Hold 2
Conditions /Comments:
Engineers:
N. 811 Jefferson
Conditions /Comments:
Utilities:
N. 811 Jefferson
Conditions /Comments:
Other:
Plan Exam
Fire Prev.
Conditions /Comments:
Application Type
(Standard unless
otherwise indicated)
❑ Fast Track
❑ Early Start
Environmental Health
W. 1101 College
Room 200
Conditions /Comments:
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either ^release" or "release with conditions"
space prior to permit issuance.)
ommercial;
New Construction;
Additional structure;
APPLICATION #
Residential
0 Bldg alteration/addition
Planning/Zoning: 0 Commercial;
N. 721 Jefferson 0 Cert. of Exemption; ❑Frontage;
0 Setbacks; 0 lot w/d;
❑ lot size; ❑use/zone;
❑ CU, variance, zone change; shoreline;
❑ Other ❑fence;
❑ Commercial; -esidential;
❑ drainage � 0 Flood Plain;
new access/approach; 0 fence;
❑ road improvements
Release
err
h
c 1•
U
co
►— E
0 2.
u_
3.
Agencies Performing Special Inspection:
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Telephone