1984, 04-05 Permit App: 84A-2952BUILDING 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)
Zip ZQ �
Department Use Only
State
Phone _
1 e k� S
V f�'�
License No.
uSi PL )
Rea. Comm
2
Project Address (not Mailing Address) or Road Nam
Space
Zi(p�J'G/j+
1,0
Phone
( )
12 Review Required Plan
Check (YIN)
Other (Y/N) SEPA
3
Cityy//C^ommunity
15 Type Work ❑ Bldg
❑ Fire
State
Subdivision/Plat Name
❑ ReplaceOther
❑ Move
(�
Stt±lrll
14 Describe Work
_TN SFA LL_ S; Vj I M M U1 61- POOL ( V I AJ I- t_ l- I N �JZ)
10 App?t Name C p
j_5
Street Addr ss
r
11 Zip
4
Assessor Parcel No.
Lot
Block
Street Address
DEPARTMENT USE ONLY
City
1
Phone
Contact Person
Phone if different than above
5
Sic Code
Zone Act. N
Zone
Project No.
6 Dwell No. of Buildings Sq. Ft./ Acre Depth Frontage
1 I
7 Set Bade -Front (L)S-1 (R)S-2 Rear Census Tract Module No. Initials
16 Architect Firm Name Street Address
Zip CityState Phone
Cont son Phone if different than above
Contractor Firm Name
Street Address
AfES
Zip ZQ �
city� �y
State
Phone _
Contact Person
c_
License No.
uSi PL )
Phone If different ttw above
8 Owner/Agent (if different than N1 ab ve)
Business Address
9 Zip City
State
Phone
( )
12 Review Required Plan
Check (YIN)
Other (Y/N) SEPA
Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ ReplaceOther
❑ Move
(�
Stt±lrll
14 Describe Work
_TN SFA LL_ S; Vj I M M U1 61- POOL ( V I AJ I- t_ l- I N �JZ)
10 App?t Name C p
j_5
Street Addr ss
r
11 Zip
Cit
Io +v�
State
W F7 `
Phone
(�-J) �) �' L- � _ L-7
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
EN
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health ❑ Commercial;
W. 1101 College ❑ New Construction;
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/ Comments:
e Residential
❑ Bldg alteration/addition
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/ Comments:
Utilities:
N. 811 Jefferson
Conditions/ Comments:
❑ I I Other:
Plan Exam
Fire Prev.
Conditions/Comments:
Project Representative
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
Telephone
Release
Release
w/cond 1
Hold 2
d.�
Telephone