1986, 07-07 Permit App: 00011975 Pool(THIS IS NOTA PERMIT)'
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHAD
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/ Owner's Name LAST FIRST MI
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Project Address (Street Name 8 Number) Zip
F le kd,c .Tnc/l co,, PI? 99027
Applicant
Address
City
oris oRcff19RD
State
u.,
ZIP
956 7
Phone
I- 3 92.z 47(L
Business Phone
Contractor/Agent
Address
City -
State
Zip
Phone -
Contact
License Number (Required)
Business Phone
- 1 )
Architect/Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
( )
Lender
Add see - .
City
State
Zip
phone
( )
Describe
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Assessor Parcel Number.' '„
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Comb: Plan • — -
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Census Tract','
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Number of DwellingUnits
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. Number.of Bulldin 81-, .o
9�w. „
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+Lot Size ($q, Ft./Acre), _ .
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Depth".',
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Frontage - ;r.
Fron[age:�x a.':9c:eur.
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„Lett Setback - -
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Right Setback oar Slb
Rear t
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Width
- Additional Information, - " - '• '--
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'" ::`h"BUILDINOINFORMATION' ' .3 "'I
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Square Footag
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Numer of Bedroom 1.
Building Technlc1.
an.
'Date'' t
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-GrouPi''^y.
4
'Type,"a;,
Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Application #
Cond.
Approval
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Utilities
❑ N. 811'Jef Person
Plan Review/Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that 1 have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application is true and correct.
Signature/el a
,041
Date 7- 7^ Fey-
Legal Description
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Show on Site Plan:
Additional Information:
Lot Dimensions
Landscaping
Existing Structures
Drainage Plan
Proposed Improvements
Hydrants
Structure Setbacks
Topography
Easements
Lighting
Septic System (s)
Signage
Water Unes
Shorelines
Sewer Unes
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
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