1985, 07-24 Permit App: 00006527 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)
SI'1AUtU AtitAJ Atit rum UtYAh(1 MCIN I AL
USE
I Project Number 652_7
Owner's Name LAST FIRST MI
02t'Infyi— Je`C-(1rN #' 1� 1 44
Project Address (Streetfame & Numb-er?-� Zip
3W/4,4). f% ri iPol 0 k 4 vi t CO 99.)i�
Applicant
nvvrl NY/)
Address
U p / 4 1L L
City }
State
Zip
Phone
Business Phone
( ) %,77 --moi?/
Contractor/Agent
Address _
City
S'130)(ca Vl
State
�)R
Zip
9921'2.
Phone
( ) 9.7v- /jSr
Contact
License Number (Required)
Business Phone
( ) 1,37-.=71a/
Architect /Engineer
Address
City
State
I Zip
I
Phone
( '
Contact
Business Phone
( )
Lender
Address
City
State Zip
Phone
( )
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DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent is true, correct, legal, and binding.
Owner's Signature Date
Approved
Cond.
Approval
Hold
/Environmental Health Permit Number— J2/c
��
College
Ro
Room
Room 200
��/�~
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent is true, correct, legal, and binding.
Owner's Signature Date
Show on Site Plan: Additional Information:
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nyaranis
Structure Setbacks
Topography
Easements
Lighting
Septic System (s)
Signage
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Flames of
Fronting Street
Flanking Street
Scale:
Date:
Revisions: Attachments: