1985, 08-09 Permit App: 00006955 Pool BUILDING PERMIT APPLICATION WORKSHEET
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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) /S(first) _,,,• ) OepartmentyeeOnly
f2A-Nr,Es, l r i- Lam- Res. . Comm
2 Project (not Mailing Address)or Road Name 1•-� Space Zip
I i 1 So S 1-1 P+�f (�La 6
3 City/Corn nity State Subdivision/Plat Name
4 Assessor Parcel No. Lot Block
(Y41112—
Y41_ p- — 42-5 Z * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No.
eFir & 5
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ / 172.66
7 Set Back-Front I(L)S-1 (R)S-2 !Rear
Census Tract I Module No. Initials
f 01-(0.)
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name
__11.--S
US Street Address �f /4/4043
�43 �f
� ..s'a 1/ 19
Zip,_ p City State Phone
/ �ut� J.rb`% ) 9 1.%7---3---0
person License No. Phone if different than above
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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) Date
15 Type Work ❑ Bldg ❑ MH New ❑ Replace ,f,:r Other/�
❑ Fire 17 Demo ❑ Add/Alter ❑ Move Jed%/h Pee
14 Desattie Work
LAfe—b ik) i S [Msii /7x2?
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
I
DEPARTMENT APPROVALS
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 W9;1("(j(
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition -r-ft
Room 200 ❑ Additional structure; TT
APPLICATION#
Conditions/Comments:
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone; ,
❑ CU,variance,zone change;shoreline; 0 fence;
O Other
Conditions/Comments:
❑ Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; I
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
0
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•a Project Representative
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Telephone
Q. Agencies Performing Special Inspection:
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• E 2
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3.
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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