1985, 07-03 Permit App: 00006222 PoolBUILDING 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)t)(m) Department 118eAnly
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1
2 Project Address (not Mailing Addre ) or Road Named // Space Zip
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3 City/Community State
...5,90/1.6A.//12:V/0
SubdivlsionlPlat Name
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4 Assessor Parcel No.
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Lot
Block
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* ,t * DEPARTMENT USE ONLY ,tit*
it
Sic Code
5 Sid
Zone Act. #T
Zone
0(6,22.
Project No.
6 Dwell M
I
No. of Buildings
3
Sq. Ft./Acre
Depth
32 (,53
Frontage
III. 2j
7 Set Back -Front
1,0
(L S-1 (R)S-2
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Rear
Census Tract
Module No.
Initials
JU pn .
r 16 Architect Firm Name
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I Street Address
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Zip✓�
City
State
Phone
( 1
Contact Person
Phone If different than above
( )
Contractor Firm Name
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Street
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Address
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City
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State
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Phone
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7
Contact Person
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License No.
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Phone If different than above
( ) ,.__-
8 Owner/Agent (if different than #1 above)
Business
Address
r--
9 Zip
City
State
Phone
( 1
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA
Exempt
(Y/N)
1
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ Replace
E Move
Other
14 Describe Work, ,
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10 Applicant Name
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Street
Ai-
Address
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11 Zip
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City
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StatePhone
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( soy) 22J -Jc fy
Lender
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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
Early Start
This is nota Permit
—!
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health El Commercial; ❑ Residential4Pe."
W. 1101 College El New Construction; ❑ Bldg alteration/addition
Room 200 Additional structure()
1
.7
APPLICATION # `6St0
Conditions/Comments•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
0 ❑ fence;
N. 811 Jefferson 0 drainage new access/approach;
❑ road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions / Comments
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments•
•
Project Representative Telephone
c
Agencies Performing Special Inspection:
1
0
a,
E
2
o`
C
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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