1984, 06-08 Permit App: 00000595 Swimming PoolBUILDING 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 U my
(241 -Ki< J EF'ra>=`i IN *o, x
Ras. comm
1
2 Project Address (n Mailing Address) or Road Name Space Zip
C iiir5 /-)- r4 Cr `il�OL4,
3 City /Community
0KtAn3
State
Subdivision /Plat Name 3
4 Assessor Parcel No.
. .x.54' 7 -- � '(
Lot Block
C( * t * DEPARTMENT USE ONLY * * *
L
5 Sic Code
Zone Act. #
Zone Project No.
6 Dwell #
No. of Buildings
Sq. Ft. /Acre
Depth
Frontage
7 Set Back -Front
I (L S -1
(R)S-2
1
I Rear `
F-6
Census Tract
1 Module No.
Initials
I
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City 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 .71 Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add /Alter
7 Replace
E Move
' Other
l C C
14 Describe Work
vv�y1,-- I ►mac. .- C:-,'• � Ie7X -`:
10 Applic nt Name �]
Fv2-t K/
1 . (L. ' K,
Street Address
11 (S L U t4i Cr'
11 Zip!
'I .7-04i
City
Seoki Ad
State
w A•
Phone
(mac I ) C l JI (p,
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
This is not a Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
Fast Track
Early Start Release
Release w/cond 1 Hold 2
�
Environmental Health ❑ Commercial; fl i Residential c.. ,
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition r
Room 200 Additional structure;
•
APPLICATION# � L(
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot wld; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
El Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
ci
❑ Project Representative Telephone
ca Agencies Performing Special Inspection:
c 1.
U O
V
c`4 Ry
F- 2.
h O
c
3.
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold
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