1985, 11-04 Permit App: 00009392 Pool Cover (THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY COTMHOSEPLETE PARTSININK OF THE FORM YOU UNDERSTAND
(Please return this original
HADED and yourAREAS building
AREFOR plans toDEPARTMENTAL the DepartmentUSE of Building and Safety)
Project Nmt�sr 1, i 7.0,
Owner's Name LAST =IRST
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2 0uC.hI k 06/6-C)71
Project Address(Street Name&Number) Zip
Applicant 'k dress f t 1 02��v� TCS2/6,
City State Zip Phone T
( )
Business Phone
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Contr. .r/Agent Address
City I 0 State Zip Phone �� ��—�
Contact License Number(Re fired) Business Phon
Architect/ sneer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
gCoven
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t � Eilock Plat Number
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Pa Pertinent Fdl $ - if } ' Comp Paan Census Tract
c�Y vs x {;,
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C.tt 'of[ elliirtg tiff ,
�i$ �'� i "sett f R/W Width
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Additional Information a Footage
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Number of Bedrooms
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DEPARTMENTAL REVIEW
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1 Approved Cproval Holdr
a APProv / 6'_
Environmental Health Application# (A- 1 0
❑
w. 1101 College � ,$�
Room 2 [
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cz,A- P c J �.�i %' (-
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
0 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 to compile said application is true and correct.
Signature � f?'! C-f — '���'- "" Date ����{/PS`
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