1986, 06-13 Permit App: 00011576 Pool (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number p5
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Owner's a /p�� Ay�/j���//� LAST ilte,114/
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Project Address(Street ame;Number)
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Applicant Address
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City S n, t State W 14 , Zip gel'Le
c Phone 379 ) �K
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91,-34:6'
Business Phone
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Contract Agent,,,,
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Cit /`yfa) Address , /cJL
State
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, 447, Zip Phone
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Contact License Number(Required) Business Phone �o'
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Architect/Engineer --
Address
City State I Zip Phone
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Contact - Business Phone
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Lender V Address
City State Zip Phone
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Describe Work r") 1 Res. Comm.
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Subdivision/Plat Name/Short Plat Number
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Assessor Parcel Number Lot Block Plat Number
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Pertinent File Numbers Zone A Comp.Plan Census Tract
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Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
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Building Technician Date Group Type
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DEPARTMENTAL REVIEW
Cond.
Approved Hold
Approval
Environmental Health Application N 1 2S. r- -4
❑ W.1101 College
Room 200 , .
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
❑ Fast Track/Special Inspection Information
Project Representative Phone
Address
I certify that I ha a xamined is application and state that the information contained in it and submitted
by me or my age t compiles: d application is true and correct.
Signature 101 Date T' //::547
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Show on Site Plan: Additional Information: I
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Lot Dimensions Landscaping ( —
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ExistingStructures Drainage Plan ( �__ . -____-_—; —`_._J. �__- T-_- ._-_— 1 _ — _ _ i�_ }
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Proposed Improvements Hydrants
Structure Setbacks Topography � I f
Easements Lighting } -Y -______ _ _ �_ { i______ —____ 1 — •_-- ,
Septic System(s) Signage
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Water Lines Shorelines ! r�0� ; i j I I `
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Sewer Lines Highwater Mark - - i _ ! _ i
Fences,Wells ' I
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Driveway(s) i --�— — �— —
Right of Way Width(s) '_ x — 1 _ f 1
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Names of •
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Flanking Street r_ j _ z • i -_ . -- - • i _ t
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