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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'