1984, 08-23 Permit App: 00001917 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 ,n/ (
(last) �(� (first) (m) Department Use Only
Gt IGCC ( o- teRW yN CmCKC`y/ Fps. Comm
2 Project Address(not Mailing Address)or Road/Name Space / Zip
/03 1(x. E . 14 '-'' qi. o
3 City/Community State Subdivision/Plat Name
QNtt �. UNI I ''AI (-1 0.0- v-'
pDk
4 Assessor Parcel No. Lot Block
/ 40S-LI -- V( 1 * * * DEPARTMENT USE ONLY(
,t ,t ,t
( 7
5 Sic Code s Zone Act.0 Zone Project No.
A 5
6 Dwell k No.of Buildings Sq.Ft./Acre Depth Frontage
1 75 (
7 Set Bads-Front I(L)S-1 (R)1-()[
Rear Census Tract Module No. Initials
[5�N� �� I I
S '
* 16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
or Firm Name Street Address
ContrG,Aa - pUf�� NC/ - . 3723 5pAau Vit ;_
Zip City State Phone
?C12.o c SQ. k, I L/V A ( )
Contact Person License No. Phone If different than above
P°-fi(r-PT U -5 ( )
8 Owner/Agent(if different than 01 above)
16/(0(
/01 Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) [SEPA Exempt(YIN) Date
15 Type Work y,Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo X Add/Alter ❑ Move
14 Describe Work , �,,, � 4 (4( X Z
10 Applicant Name Street Address
al r R k...) y ti i c.. C I I A f 6 y -6.4
11 Zip City State Phone
�tgav� S co 1c�1 ru-e �.r (5O ) ?,18 .7 S-a s-
* Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
This is Mot a Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
0 Fast Track i
O Early Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; ElResidential Vu!
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Z:;Z1
Room 200 CIAdditional structure;
APPLICATION#
Conditions/Comments:
D Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; El fence;
❑ Other
Conditions/Comments:
O Engineers: El Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
O Utilities:
N.811 Jefferson
Conditions/Comments:
EI
Other:
El Plan Exam
Fire Prey.
Conditions/Comments:
a
w
c
s Project Representative Telephone
ca Agencies Performing Special Inspection:
Y O
c 1.
U —E
i E 2
yo
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LL
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 S�
5301 N.E.105th AVE.,PORTLAND,OREGON 97220(503)255-7900
SPOKANE OFFICE
W.318 BOONE,SPOKANE,WASHINGTON 99201(509)325-4513
TOLL FREE TELEPHONE NUMBERS V?/7// 7/ .S
IN OREGON(800)452-3746
OUTSIDE OREGON(800)547-3680 al, f,
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