1985, 05-15 Permit App 00005424 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 (last) / (first) (m)
C s 1 �i (1 G Tl/ ' f) f%/�i'��%/�
Department Use Only
Res.
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
64/.2s=Je-Of/Pres,eci).. J7r .
3 City/Community
s il/%/1•c—
State
14)/'9s r( • _
Subdivision/ Plat Name
I t ri,� ors , 4e4r &. fl .
4 Assessor Parcel No.
cic.
Lot
is
Block
( I
* * * DEPARTMENT USE ONLY * * *
4 5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
1 (L)S-1
(R)S-2 I Rear
Census Tract
I Module No.
Initials
i
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Arm Name
r !'/— L Fi p r✓ G hi •
Street Address
Se/ -hi/ x s'._ 0 l'ei 1— 4°er _ ./J-•— ,
Zip
7P-e, f
City
5 ��l`� �/F _
State
id/r'S /�
Phone
(sag ) f'.2 - d r 7
Contact Person
License No.
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
_
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN)
I SEPA Exempt (YIN)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
zS' w, i•M1 f h/ r r (7,1 f• — /t /;v i/Cr: C W.0 G• /t/ /_2 .
10 Applicant Name
Ir/A:: 1,(AtG-tN. 0— r/t2ge,eg_
Street Address
hcias',se - 0 /' .7'4,,.,47 -/' ,
11 Zip
9yzO 4
City
,/'6WdsficiF
State
4Y-45-1Y,
Phone
(s.) £z-- o f e7
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions/ Comments•
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Release I
Release
w/cond 1
Hold 2
"Oa
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments.
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
❑ road improvements
Conditions/ Comments•
Utilities:
N.811 Jefferson
Conditions/ Comments•
Other:
Plan Exam
Fire Prev.
Conditions/ Comments'
Project Representative Telephone
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
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