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1984, 04-18 Permit App 84A-3498 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 Owner's Name (last)) (first) (m) Department Use Only 'e &C4 M / ...ee� .4. I Res. Comm 2 Project 17, Mailing A154aacia/ � Space Zip Cr7, / 3 City/Community 5P©,4' 44 -c State cam' r Subdivision/Plat Name o F?om i I a-i 5 87 4 Assessor Parcel No. / ' 5 9 ' /._ p 7/ ( 7 Lot Block * * * DEPARTMENT USE ONLY 5 Sic Code Zone Act. # Zone Project No. 6 Dwell # 1 No. of Buildings t Sq. Ft./Acre Depth Fronts e V p 7 Set Back-Frontk- A �1_ _ (L S-1 r Y i 71 . /` (R)S-2 Rear I : %I Census Tract Module No. I Initials J U fJ M 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone If different than above ( ) Contractor Firm Name / e:' e1/f�) /�U/NS /' /t/';� l Street Address �/J At9 /D /!/�'/�9%/ P./�'.J /P 66L Zip 99�/4. City Z720 t° State -2-6/47 Phone 7 ( ) 9a - 70/02 Contact Person License No. e I 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) Other (Y/N) 1 t SEPA Exempt (Y/N) Date 15 Type Work ❑ Bldg 0 Fire El MH 0 Demo ❑ New B---Add/Alter 0 Replace 0 Move 0 Other 14 Describe Work Waif' 11 // 1 /�Q 1041/ -6A5/�Leg/c-e 10 Appli t Nameeaat// _ / ��f2O��Gf/ //r%S-/ ' Street Address /� / 4 /O nvi. lfjf� e. , e 12 cY 11 Zip 9.9.2/ City 5 P/Gq/r/2 State 4 Phone T ( ) 9,-(- 70 �.. Lender Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Information a y c 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 Conditions/Comments ❑ Commercial; ❑ New Construction; ❑ Additional structure; APPLICATION # s C: ❑ Residential ❑ Bldg alteration/addition Release Release w/cond 1 Hold 2 MEll Planning/Zoning: 0 Commercial; ❑ Cert. of Exemption; ❑ Frontage; N.721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; D use/zone; ❑ CU, variance, zone change; shoreline; 0 fence; ❑ Other Conditions/Comments Engineers: 0 Commercial; 0 Residential; 0 Flood Plain; N.811 Jefferson ❑ drainage 0 new access/approach; ❑ fence; O road improvements Conditions/Comments Utilities: N. 811 Jefferson Conditions/Comments Other: Plan Exam Fire Prev. Conditions/Comments c s 0 E oo c6 C LL 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