1984, 08-29 Permit App: 00002003 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)
fV ��2
Department Use Only
Res.
Comm
2 Project Address (not Mailin Address) or Road Name Space Zip
- 3 los,1.'I1:y eT '
3 CI /Community
0/C
State
Zi -4 1F--
Su (vision/Plat Name
/0/.1,9-6/2.0 .,t- 777/72 & d'ra--
4 Assessor Parcel No.
3 Z S '/ _ //_ /V
Lot
/ (./
Block
8 Z
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone! - (
'
Project No.
,, 3
6 Dwell #
No. of Buildings I
Sq. Ft./Acre
Depth I 1
(0 D -I
Frontage
110'
7 Set Front
i [711N &.
(L S-1
I _7 Z
(R)S 2
�i
Rear
-
(bnsus Tract
Module No.
Initials
J 01,1 Yo
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Atractor Firm Name
L e2z c-
Street Address
61 (3.s2 cr,,,exT 6 4
Zip
? q
City ,</ �' /C flit /
State _
�i
Phone
Phon (SOO-5-S'..c
/Contact )
d�r�/� / 76/1/6 d N
Li se N/o. I p
v / W �yt/ e-/
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)
1
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
X New
❑ Add/Alter
❑ Replace
❑ Move
r+, Other ��/'J�
J"" "` �� ' - d"__-
14 Describe Work k
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
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
❑ Addition tr c+ture;
APPLICATION #
Cc((
Release
Release
w/cond 1
Hold 2
il._.:-.) 0
Mill
Conditions/Comments.
Planning/Zoning: ❑ Commercial; E Cert. of Exemption; E Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments•
Engineers: ❑ Commercial; 0 Residential; ❑ Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions /Comments:
Project Representative Telephone
Agencies Performing Special Inspection:
1
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
.0//