1985, 06-06 Permit App: 00005783 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 jj�''pp ��(Iaast) ^� (first) (m)
ffirE �C 11 / E/Fn Y
Department Use Only
Res.
Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
4/, / /? /?R -- 79.209
3 City/Community
spevIr%f 4---
State
ceiA ,
Subdivision/Plat Name //
Off 12. ml5: o►J to
4 Assessor Parcel No.
ftW q.-1-_ D� ��
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone P / e , ^
Project No.
6 Dwell #
No. of Buildings
I
Sq. Ft./Acre
Depth
/9T 1
Frontage
8s'
7 Set Bads -Front
(L)S-1
(R)S-21Rear
Co'26`
(anus Tract
Module No.
Initials
JUNM.
16 Architect Firm Name
.. PAX/4L- Poepcs z'vc,
Street Address
AK5-45-o C��-�
Zip
9'9' Ato7
City
s1,(Yri 4/4-
State
1-4)4 ,
Phone
) «7/'
Contact Person
iF, Dr kI,445�
Phone if different than above
( )
Contractor Firm Name
,Z'/"WPEJ/4,- ,L $ ---/f/''/
Street Address
44_57,3-29,r�4-1:4
Zip
79',?D 7
City
5/19A-iieE
State
kfQ .
Phone
(3N > % S 67'
Contact Person
/i f Dr (Z¢4.5�{
License No.
X/'/PiX/*.a7 PT
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
d
3'1
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) 1 SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
X New
❑ Add/Alter
E Replace
❑ Move
�fOrOthef
std /pVat.
14 Describe Work
S (A,l !At/V!/YG FAL ‘49e1(ST1'l)G771)Af
10 Applicant Name
I), IVAL5#
Street Address
44 s -/!o /rkEY4
11 Zip ? 0 07
/® � 4/4
State .
Phone
S Ts/ J -4,75
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial; ❑ Residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
1/�
J�
APPLICATION #
Conditions/ Comments•
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments•
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; ❑ fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial;
❑ drainage
O road improvements
❑ Residential;
❑ new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/ Comments •
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative
Agencies Performing Special Inspection:
1
Telephone
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Release
w/cond 1
Hold 2
'R/eellease
Conditions/ Comments•
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments•
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; ❑ fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial;
❑ drainage
O road improvements
❑ Residential;
❑ new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/ Comments •
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative
Agencies Performing Special Inspection:
1
Telephone
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
489-5674
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