1984, 06-28 Permit App: 00000919 PoolBUILDING PERMITAPPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF T_NE 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)
Ai9fPt`7d
A /1 A/ j"
Department = • ly
Res.
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
/3 3615/ E /Pi c h X7'7 / C
3 City/Community
'S Po/rig N ,E
State
.1 s A
Subdivision/Plat
5 t
Name
IVoa A b0
4 Assessor Parcel No.
( _ .3c)
b51
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 0
Zone
Project No. 9 /
6 Dwell */ f
No. of Buildings
Sq. Ft./Acre
I
Depth
Frontage
7 Set Bads -Front
(L)S-1
f
(R)S-2Y
Rear
Oansus Tract
I Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone if different than above
( )
8 Owner/Agent (if different than 01 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other.(Y,/N)
�l/
SEPA Exempt (Y/N)
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
E New
E Add/Alter
E Replace
E Move
6C -Other
14 l ibe Work � �Jhe � 1 / '‘S
x--11- t.Ld 1 ie _/./...s-1 �(f,{ �y�j S k 3� ` 4) ST P
7.7
10 Applicant Name /J
Street Address
11 Zip
City
State
Phone Gi j
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
7Early Start
inisisnot arermit
r.
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
lg
Environmental Health El Commercial; esidential�'
Room 200 Additional structure;t---g-
W. 1101 College ❑ w Construction; ❑ Bldg alteration/addition
("�'
J
APPLICATION # S- Ll
Conditions/Comments.
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions /Comments
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new 0 fence;
access/approach;
❑ road improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments.
•
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
1 Information ❑1
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
r
1