1984, 10-03 Permit App 00002491 DuplexBUILDING 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)
er's Name t) first) (m)
Department Use Only
Fes. Comm
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2 Project Address (not Mailing Address) a Road Name Space Zip
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3 City/Comm ity
State
Subdivision/Plat Na
4 Assessor Parcel No.
Lot
.�'
Block
* * * DEPARTMENT USE ONLY * * *
l
11� �/ — 1 j ,y
5 Sic Code
Zone Act. #
Zone ,• el 9 OS
Protect No. 2,4e1
6 Dwell#
No. of Buildings
1
Sq. Ft./Acre
I Depth t
I (213
Frontage
Mtn' .
7 Set Back -Front Front J
(L S-1 i
I(
(R)S-2 J Rear
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Csnsus Tract Module No.
Initials p t /�/�
JUt 11' l
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name f
Street Address 4 ' /,
Zip
/-.
City
i4„."
State
��F�
Phone
_ ��oG
CA Person /�
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License No./
i2,0M p4 GG 1 OCP try
Phone if different than�
( ) � - fo,,,7
8 Owner/Agent (if different than #1 above) 19 Si or / S' .�
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN)
SEPA Exempt (Y/N)
Date
15 Type Work Bldg
❑ Fire
0 MH
0 Demo
,. New
0 Add/Alter
0 Replace
0 Move
❑ Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
I
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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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.)
Er
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
L�7 New Construction;
❑ Additional structure;
APPLICATION #
❑ Residential
❑ Bldg alteration /addition
?/-//35‘•
Release
Release
w/cond 1
Hold 2
Conditions/Comments- /.P-,Ltd-Z-; /l � rev-r-4 l /per/ �7 .,h�/. Q f
�+ / dTi
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments-
Engineers: 0 Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage El new access/approach; ❑ fence;
❑ road improvements
Conditions /Comments'
R
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
Plan Exam
Fire Prev.
Conditions/Comments-
G✓J
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