1985, 04-17 Permit App: 00004979 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 Use Only
��/� I
t
Il Y I 1 (11 VIA X( ,CUAC Rm. Comm
2 Project Address (not Mailing Address) a Road Name Space Zip
.an37 VIA ,E-- C(.
3 City/Community
641AI E
State
CS S Z-.
Subdivision/ Plat Name
PaN t>0s - /VP
4 Assessor 1
) 5-1
No.
I l 1
( 1O
Lot
10
Block
2— it it . DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone Project No. G
(
6 Dwell N
f
No. of Buildings
1
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
111 �
(L)S-1
-
(R)S-2
-
Rear
1!
Census Tract
Module No.
Initials
,j UN .
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor F m Name
HC)t (C(A�� ,�c)o 1 �
Street Address
� 2X) it( /_ rui v<OG (
Zip
Z° 7
City
S pe4 w aIC
State
cJL) A-
Phone
( ,t 2 - e-/,07
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 (YIN)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
0 Add/Alter
❑ Replace
❑ Move
)4.... Other
14 Describe Work
1G 3C Poo
10 Applicant Name
Street Address
11 Zip
City
State
- Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis is not a Hermit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional str cture;
cam
, "�J
1'l
'
.../
APPLICATION # 0.-! i 9
Conditions/Comments.
•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments.
11
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new 0 fence;
access/approach;
0 road improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments.
IInformation O
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
/0