1985, 08-01 Permit App: 00006649 Pool(THIS IS NOTA 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)
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Project Number
Owner's Name LAST FIRST MI
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Project Address Streef Name & Nu ber)
Zip
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Applicant � �
Address
Cit
State
Phone
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Business Phone
Contr for/Agent
Address
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City
State
Zip
Phone
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License Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender Address
City State Zip Phone
Describe`Nork
Res.
Comm.
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Subdivision/ Plat Name/ Short Plat Number
+y
Assessor Parcel Number
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
P, 6
Number of Dwelling Units
Number of Buildings
Lot Size (q. Ft./Acre)
Depth
Frontage
Front Setback
Left Setback
RightSetback,
Rear Setback
Additional Information
W
Square Footage
C/J
H
Z
W
cc
Q
a
W
Q
Building Technician
Date
Group
Type
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DEPARTMENTAL REVIEW
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.
Owner's Signature
Date
Approved
Cond.
Approval
Hold
Environmental Health Permit Number
W. 1101 College
Roo J
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Planning/Zoning
N. 721 Jefferson _
Engineers Permit Number
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
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.
Owner's Signature
Date