1984, 08-13 Permit App: 00001729 Pool •
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)
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1 Owner's Name (past) (f st) ( I Department Use
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2 Project Address(not Mailingesa)a-RRoad NNie r�J Space Zip
3 City/Communit Stat Subdi ion/Pla/Name
4 Assessor Parcel N Lot Block
2-0/1// 02.C/ /p 7 it * * DEPARTMENT USE ONLY * * *
x 5 Sic Code �[�( Zone Act.# Zone ( Project No.
5F g—.
i 6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
J 7 Set Back-Front 1(L)S-1 (R)S-2 I Rear Census Tract Module No.
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* 16 Architect Firm Name 1 '— *
,//�, y StreetjodrB(/�j.I,B`� r .
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Zip ��,�, City I State r 1 Phone
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Contact Person +- ) I Phone if different than above
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Contractor Firm Nam Street Address
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Zip City \\ I State Phone
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Contact Person License No. Phone If different than above
( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y
YIIN) SEPA Exempt(Y/N) Date
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15 Type Work ❑ Bldg ❑ MH f New ❑ Replace lOther��c:11C—.
❑ Fire 0 Demo 0 Add/Alter 0 Move
14 Describe Wrk 1
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10 Applicant Name \ Street Address
11 Zip City State Phone
( )
*
Lender• ),.\ / ' / f `�a )61
Street Address *
Zip t✓ City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
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; Et esidential
W.1101 College ❑ ew Construction; ❑ Bldg alteration/addition
Room 200 fi Additional s ucture; 0e
APPLICATION# Cif((S7
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; 0 fence;
O Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
C7 Utilities:
N.811 Jefferson
Conditions/Comments:
CI
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
a
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Project Representative Telephone
ra Agencies Performing Special Inspection:
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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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