1984, 08-10 Permit App 00001705 Canopy•
BUILD/PG 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) (f' (m) Department Use Only
w iXl i� to !„
L ��c�1/� r
0 .&t e 1J-�
Ass.
1
Comm
2 Project Address (not Mailing Address) or Road me (}' Space Zip
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r 1 /"4 5e' . C kd—t.J l �. ve
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3 City/Community
State
SubdivlsionlPlatName
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4 Assee9or Parcel No.
2 C9 — ° 3L .'
Lot
Block
* * * DEPARTMENT USE ONLY
5 Sic Code
Zone Act. #
Zone
Lcl�l in
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
I (L)S-1
(R)S-2 'Rear
Census Tract
I Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
x
Contractor Firm Name
C� C17i"7Lty
1 i.
Street Address
j'� � / �J y�
!� 1? le„ 7 St/ _ a c,
Zip
ty
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 (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
(1}CN 0 CY
10 Applicant Name t j
bCC �� J ul A l CJ
Street Address �'
s I +.`tc:1,4 Sple c. Q
11 Zi`p/� f r -
City Y' (
State �';
Phone
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
,'00 ("4
ZJ')P,uAI I 400„ 4,40, i. -
I ) 1 _2,b
•
DEPARTMENT APPROVALS
Application
This is not a Permit
I.
Type
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Early Start
Release
Release w/cond 1
Hold 2
Environmental Health ❑ Commercial; E Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
aY
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other 410/
Conditions/Comments•
al
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
`
Fire Prev.!
id
-J 7-
Conditions /Comments• A/, // >L list/' Jam. .4 .f�Ai
3 it/o.OY /. .4 .i.....` d
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t � ir it 'a. - .:rs - .e/ d j Aar . _ 'fa. . ' /c.4d9t/.S
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I/ e.Q7,-,2„/J, 14,' f(/AJ 7 . ,tt. I— i ec . / '.70 r*-1 e.
1 Information ❑
.,r'e
Project Representative A„„ _ID i /4.1/0 Telephone
.✓cxt.:p .0
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