1984, 06-11 Permit App 00000623 MHBUILDING 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)
mentUse I
li('f//fi-4 C
Comm
2 Project Address (not Mailing Addddrress fr Road Name Space Zip
//�V 7 c4,Z ? S k 99ao4
3 City/Community
s Pot,4-&ue__
State
r,J,4sGk-
Subdivision/Plat Name
fi+,k.,a es Obi:ie./4s4le sSiscif 0,s,aa
4 Assessor Parcel No.
Lot
Block
ags//"' ZO jtZ
rZ
I
(
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
12M 4+
Project No.
I. 6 Dwell #
t
No. of Buildings
I.
Sq. Ft./Acre
Depth
‘�1
Frontage
l0411 t
7 Set Back -Front (L)S-1
E.X./ STt 11
(R)S-2
Rear
Cb nsus Tract
Module No.
�
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
"3w ,e S'e
oe2 WVIoVt. Le 146.w
Viie
-e
I Street
Address
Zip
Clty
1 State
Phone
( )
Contact Person
6Le,)) "jowe,CZ_
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)
Other/N)
I
SEPA Exempt
(YIN)
Date
15 Type Work ❑
0
Bldg
Fire
111.. MH
0 Demo
❑ New
0 Add/Alter
❑ Replace
0 Move
0 Other
14 Describe Work
3 Locr
o kit Le b4, v e.
SI1V4t
(RE euNc
wlO 14r/6
s ex(sT,n4
10 Applicant Name
W i 1(4-•w.- 'L. >a
‘A cL
Street
Address
k //4 / 7 ei421 i s2.. >L
11 Zip
9QZoc
City
Sat-c_
State
(Ai ps(1
Phone
(C°/) `i'zz-a91
nder
o k cl IA e ijrn p�.
I.e.,- rred . d Rtd.,73.- 4,,„..,..)
Street Address
4 // o / c .f Af e ..C' a •J
Zip I
99zo1 .
City
Sao I�R -
State
wAV 4
Phone
(sag) gap- 9-C-9?5"
Contact Person
Phone if different than above
( )
Additional Information
i/
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;
O Additional structure;
Residential
0 Bldg alteration/addition
APPLICATION #
Release
Release
w/cond 1
Hold 2
� Lt. '
�
/
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments:
Utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prev.
Conditions/Comments'
r
Information
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