1984, 08-17 Permit App: 00001838 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)
1 Owner's Name (last) (first))/n �,(m) Department Use Only
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2 Project Address(not Mailing Address)cr Road Name Space Zip
Csrs' E to ..7/t/Z--
-J&,'" 3 City/Community State Subdivision/Plat Name
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4 Assessor Parcel No. Lot I Block * * * DEPARTMENT USE ONLY * +
2-`t5>-(- i Zl� ,t
5 Sic Code Zone Act.# Zone Project No.
'0'7 )
6 Dwell# No.of Buildings Sq.Ft./Acre Depth C Frontage
1 1 k44O q `
7 Set Back-Front I(L)S-1 (R)S-2 tRear
Census Tract Module No. I s
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* 16 Architect Firm Name Street Address
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Zip City State Phone
S"k"r 4 f vYAIS// ( ) 92Z —/too
Contact Person Phone if different than above
( I
Contractor Firm Name Street Address
Zip City State Phone
( )
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/N) SEPA Exempt(Y/N) Date
15 Type Work 'Bldg ❑ MH ❑ New ❑ Replace , Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move P60G
14 Describe Work
%WYX G1&'HHN/, ,4x' -
10 Applicant Name Street Address
/{O c /4f4/ i"IDL L /Q d"10 E !d_
11 Zip City State Phone
* Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
e
DEPARTMENT APPROVALS
This is not a Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
herwise indicated) space prior to permit issuance.) r
R
Fast Track Early Start Release
it
Release w/cond 1 Hold 2
Environmental Health ❑ ommercial; Residential
W.1101 College ❑ ew Construction; ❑ Bldg alteration/additionaril
Room 200 Additional stru ure; "� `-
�
APPLICATION# 'S / /
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; ❑ fence;
❑ Other
Conditions/Comments:
❑ Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
. N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
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Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
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as
Project Representative Telephone
ca Agencies Performing Special Inspection:
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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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• PORTLAND OFFICE
y 5301 N.E. 105th AVE.,PORTLAND,OREGON 97220(503)255-7900
SPOKANE OFFICE .
,' W.318 BOONE,SPOKANE,WASHINGTON 99201 (509)325-4513
.r TOLL FREE TELEPHONE NUMBERS ```' ti ter.
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:r , IN OREGON(800)452-3746 ~�
c• q.3 OUTSIDE OREGON(800)547-3680
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