1985, 09-03 Permit App: 00007335 PoolDEPARTMENTAL REVIEW
I certify that I h
by me or my ag
Owner's Signature
C ,&'ras9-eta 2--
e examined this
s true, correct,
pplication and state that the information contained In it and submitted
al, and binding.
Date
OA -
(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owner's Name
LAST
WAIST`
FIRST
ReNIb
MI
Project Address (Street Name & Number)
Appliray�
Zip
991-0
(I? ?I
Address
(/9 ,kid, RA,�11 ,
CItY
State toc
Zip'
4ia)(.;
Phone
Business Phone
(.r
Contractor/Agent
(?'tc re) M f L
Address
It /4ith !%nibs ,fid
City
State ,
(.lam4
Zip q.96
Phone
Coni
`) (,Vsr�1-V-1k/)
License Number (Required)
c,ttsroPat'-,Gl DP
Business Phone
ij'?) f/-? J2t'7i9
Architect/Englneer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
caty
State
Zip
Phone
/ X36 £n t,,r —. Pim:
Subdivision/Plat Name/ ort Plat Number
0
-:AssessorParcelNumber
drq'w -02
Pertinent File Numbers -
Lot
!a
Zone
Comn1:
4'eoic Aft B f
BI6ck
Coma. Pian
Census Trait
Numberof Dwelling Units
Number of Buildings.
Lot Size (Sq: Ft./Acre)
Oepth -
Frontage
Front Setback - -
;Lett Setback
Right Setback
Rear Setback
'Addilmnallnformation
Square Footage_.,
W
rn
1-
F.
z;
to
2
rc
a
ID
0
Sultdtng Techniolan
`JO 1\1 m
Date
`� 3-8r
Group
ApprovedCond.
Approval
Hold
h j
Environmental Health Permit Number U 7(0 J 6
) cd/'-
W. 1101 College -
Room200
I
I•!
)O�
)
c'
lei la /dere a etto://
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Materlal/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that I h
by me or my ag
Owner's Signature
C ,&'ras9-eta 2--
e examined this
s true, correct,
pplication and state that the information contained In it and submitted
al, and binding.
Date
OA -
(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owner's Name
LAST
WAIST`
FIRST
ReNIb
MI
Project Address (Street Name & Number)
Appliray�
Zip
991-0
(I? ?I
Address
(/9 ,kid, RA,�11 ,
CItY
State toc
Zip'
4ia)(.;
Phone
Business Phone
(.r
Contractor/Agent
(?'tc re) M f L
Address
It /4ith !%nibs ,fid
City
State ,
(.lam4
Zip q.96
Phone
Coni
`) (,Vsr�1-V-1k/)
License Number (Required)
c,ttsroPat'-,Gl DP
Business Phone
ij'?) f/-? J2t'7i9
Architect/Englneer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
caty
State
Zip
Phone
/ X36 £n t,,r —. Pim:
Subdivision/Plat Name/ ort Plat Number
0
-:AssessorParcelNumber
drq'w -02
Pertinent File Numbers -
Lot
!a
Zone
Comn1:
4'eoic Aft B f
BI6ck
Coma. Pian
Census Trait
Numberof Dwelling Units
Number of Buildings.
Lot Size (Sq: Ft./Acre)
Oepth -
Frontage
Front Setback - -
;Lett Setback
Right Setback
Rear Setback
'Addilmnallnformation
Square Footage_.,
W
rn
1-
F.
z;
to
2
rc
a
ID
0
Sultdtng Techniolan
`JO 1\1 m
Date
`� 3-8r
Group
Show on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
J b')- as 1, 0944
Scale• titff r Pssr
Date: r77.fis—
Revislons' Attachments'