CITY OF LACEY
Community Development Department
420 College Street SE
Lacey, WA 98503
(360) 491-5642
S.A.M. PLAN NUMBER:
OWNER:
Address: City: State: Zip:
Contractor: Phone: Email:
Address: City: State: Zip:
Contractor's License No. Exp: City Bus. Reg.
Plumb Contractor: Phone: Email:
Address: City: State: Zip:
Contractor's License No. Exp: City Bus. Reg.
Mech Contractor: Phone: Email:
Address: City: State: Zip:
Contractor's License No. Exp: City Bus. Reg.
Electrical Contractor: Phone: Email:
Address: City: State: Zip:
Exp:
Phone Number:
Phone Number: Email:
City Bus. Reg.
CONTACT PERSON:
THIS APPLICATION MUST BE ACCOMPANIED BY TWO FULLY DIMENSIONED SITE PLANS AND TWO LANDSCAPING PLANS
the above described property will be in accordance with the laws, rules and regulations of the State of Washington.
Applicant's Signature Print Applicant's Name Date
Pre-Approved Stock Plan Application (Site Specific)
I hereby certify that the above information is correct and that the construction on, and the occupancy and the use of
Contractor's License No.
Fax:Cell Phone: Email:
FOR RESIDENTIAL NEW SINGLE FAMILY
Project Address:
Parcel Number: Lot Number: Subdivision:
FORM: AppSam-2 / 10-07
