1985, 07-10 Permit App: 00006332 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 '�'�
Owner's Name LAST pp ST MI
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Project Address(Street Name&Number) Zip
SAM/ -- /...5. 6 5A1(. 4//2- 111,4 f ipfC
Applicant Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
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/ City Stateq�� �i Zip
Phone �/
Contact License Number(Required) Business Phone
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' Architect/Engineer Address
City State I Zip Phone
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Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
Describe Work Res. Comm.
lPl.. wkiNC, 'OO(,
Subdivision/Plat Name/Short Plat Number
(D1 GnetkLACM
Assessor Parcel Number Lot Block Plat Number
Pertinent.File Numbers Zone Comp.Plan Census Tract
Pl-
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage .
Front Setback. Left Setback Right Strb4 1 Reart
Se back
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Additional Information Square Footage
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Building Technician' : .Oats
t3roop. .Type
DEPARTMENTAL REVIEW
Cond.
Approved ,Approval Hold
0;f( J prov
Environmental Health Permit Number S /
❑ W. 1101 College \ /'�'
Room 200.c7A.Q.A.4 ))1„ftiA 401. n
Planning/Zoning
❑ N.721 Jefferson
Permit Number
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
0 N.811 Jefferson
Other(SEPA/Critical Material/etc.)
El Fast Track/Special Inspection Informatign
Project Representative Phone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent is true,correct,legal,and binding.
Owner's Signature Date
•
Show on Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants
Structure Setbacks Topography
Easements Lighting +!
Septic System(s) Signage
Water Lines Shorelines
Sewer Lines Highwater Mark
Fences,Wells E
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
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Scale:
Date: 7''
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Revisions: Attachments:
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