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1984, 04-17 Permit App: 84A-3455 PoolBUILDING 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 first) (m) Department Use Only Mas V R3s. Comm I 2 Project Address (not Mailing Address) or Road Name vii Space Zip I' I C . r 11—'— gq 0 3'7 3 Gtylt_ Viie-A+A State W 13 Subdivision/Plat Name JS A Pt) / 77 o fit/ 4 Assessor Pprcel No. c S- (/ / ' r Lot 7 f Block I / I * * * DEPARTMENT USE ONLY * * * il5 Sic Code Zone Act. # Zone Project No. 6 Dwell # No. of Buildings • Sq. Ft./Acre l Depth Frontage 7 Set Bads -Front I (L)S-1 (R)S-2 I Rear Census Tract I Module No. Initials 16 Architect Fir Name Street Address Zip / / City State Phone ( ) Contact Person' Phone if different than above ( ) ContractorFirmName CLt&r M YoDL- Street 1 Address 1 q f° Yi t '''The! Zipiqq �� Cft p K K. t1 1 StateW Phone Li) q -S3,79 aContact (' [� N V�.i WJ2�IV License No.[�i / j� Lus r©1 * 14.1 b P Phone If differ�han above 8 Owner/Agent (if differ han N1 above) Business Address 9 Zip City State Phone ( ) 12 Review Required Plan Check (Y/N) Other (Y/N) SEPA Exempt (YIN) Date 15 Type Work D E Bldg Fire ❑ MH ❑ Demo ❑ New ❑ Add/Alter 7 Replace ❑ Move E Other 14 Describe Work 10 A Iicant N �t,t-&`r-E-tom 1? r� S -' t•:i kos Street i Q/ fr Rb/ 11 Zip__- ^ � !mss�� City 42.4 StatePhone Ltii:r ?) ? ��7q Lender/ / Street Address Zip City State Phone Contact Person Phone if different than above ( ) Add itin1,1 Information 00 DEPARTMENT APPROVALS 1 Indicate above or attach conditions relative to final as built approval 2 indicate above or attach reasons for hold Application Type (Standard unless otherwise indicated) Fast Track Early Start IHIS ISHUIarerrnli (Indicated approvals required in either "release" or "release with conditions" space prior to permit issuance.) Release w/cond 1 Hold 2 KEnvironmental Health ❑ Commercial; El Residential W. 1101 College X New Construction; ❑ Bldg alteration/addition Room 200 ❑ Additional structure; �\\Release Dd' �!,/8�{ T APPLICATION # /3 • -- 0 S c) Conditions/Comments• FDk t cL 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; ❑ ❑ fence; N. 811 Jefferson ❑ drainage new access/approach; ❑ road improvements Conditions/Comments• Utilities: N. 811 Jefferson Conditions/Comments• Other: Plan Exam Fire Prev. Conditions/Comments Project Representative Telephone Information Agencies Performing Special Inspection: 1 2 3 1 Indicate above or attach conditions relative to final as built approval 2 indicate above or attach reasons for hold