1985, 09-05 Permit App: 00007343 Pool • • (THIS IS NOT A 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 FIRST MI '
P-1-7//9 Wald L .
Project Address(Street Name&Number) u
Zip
£. to cil 3 --ohte, w f9 99037
Applicant Address
G . /( q13 _74`'
cit State Zip Phone
\i'eVOJO l'e COq 1037 ( 50) q )-69 )3
Business Phone _
(S01 ) `fS(,- SSQO
Contractor/Agent I Address
City State 1-Zip Phone
( )
Contact License Number(Required) Business Phone
1 1
Architect/Engineer 1 l Address
City State I Zip Phone
I (Contact Business Phone
( 1
Lender Address
City State Zip Phone
( )
Describe Work , Res. Comm.
u`4- t (1.1 1n SW1V VYl( i� poo( x
Sub-division/Plat Name ort Plat Number -
1Z 7C )ro k ieE-$ l RAC r�,S
Assessor Parcel Number Lot Block Plat Number
,11.5V3 - Olrc r(k. -
Pertinent File Numbers zone., Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
f.6,e Ac c-�
Front Setback Left Setback Right Setback Rear Setback
Additional Information Square Footage
w
N
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f- _
Q
Q
a-
w
0
BuildingTechnician Date Group Type
*II) 9-5-85 .
•
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
1 •
Environmental Health Permit Number _18:___4_ESTI__ `' K
W. 1101 College 0 1 ` 1(Room 200
Planning/Zoning
u N. 721 Jefferson _
Permit Number
Engineers
❑ N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
1-I N.811 Jefferson
Other(SEPA/Critical Material/etc.)
n Fast Track/Special Inspection Information
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.
71 ,
Owner's Signature (- !` / Lam_ / �Z � Date f—/.`- '=✓ -:
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