1985, 05-13 Permit App: 00005396 Pool _._.__,/,_____________.._ =__-,,c.�.. .
BUILDING 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)
PA) 5'1,4 •-Oni
1 Owner's Name C(last) /(first) (m) Department Usepnly
S1 ibEVE- bAkt v fes. ✓ Comm
2 Project Address(not Mailing Address)cr Road Name Space Zi
/4,1/3 c-S i to 9 U zi
3 City/Comm ty State Subdivision/Plat Name
Pd fL c_,-- ( LL-L-L5 LAY 04# o i----
4 Assessor Parcel No. Lot Block
dl�cfZ — Z5a7
* * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone �� Project No. 53q6
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/J
7 Set Back-Front (L)S-1 (R)S-2 Rear Census Tract Module No. Initials-t
CCS`` (e/
* *
16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm NameStreet Address
CL itS ,r t PALS ! lig Lk P( m t.s
399, '1 .0 Co
CicSre) StatePhone,S
^ 7 s-L-77
n Con Person License No. Phone if different than above
1
8 Owner/Agent(if different than#1 above) 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 E MH KNew ❑ Replace it3 Po®�
❑ Fire ❑ Demo ❑ Add/Alter El Move
14 Descr Work
t3rA i, I SvJ f M MI 07— POO 1. 16 x 31/ ci7 Cri--£�
10 App t Name �-- n�L 1��� Street Address
11 Zip City State Phone
*
Awe -- ( ( )
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
9,#4-f...-L- .2/G ` 9,-'},3..' 1±677/-rk G— IAA% £ �s'iavt..L11
,CJ 1-0411— PAO L-,
b v Ai SSP;-L LiA1 _, /t-t✓o vii.-1) ,
DEPARTMENT APPROVALS `V
This is nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
Fast Track
Early Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition /
Room 200 ❑ Additional structure;f 7 /
APPLICATION# gr—CLI) 17/73
Conditions/Comments:
❑ 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; 0 fence;
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
El
Other: I I
❑ Plan Exam
Fire Prey.
Conditions/Comments:
a
c
m Project Representative
Telephone
0.a Agencies Performing Special Inspection:
1.
Y O
f0 as
E 2.
ao O
oc
LL
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
r .
-
T
11
t\i/je
L
II
11i
'
i 10-
?.-44
vr.
SI:1k_
e Ate —
2 (
/
5'1-- iatT
tt....<,
ILO (