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1984, 04-03 Permit Application: 84A-2864 AdditionBUILDING 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) Department Use my 1...r1�1•1►-T L Rte. Comm I 2 Project Address (snot Mailing Address) cr Road Name Space /ZZip�y \ V " -�^ -� 1X4 -1. g� r...IZrea 3 City/Community '''`''''I Pw (4 State •0 p., Subdivision / Plat Name C.A,- P4 C N ? A o 4 Assessor Parcel No. 1 ©5 1 a Lot ' 2 Block * * * DEPARTMENT USE ONLY * * * 5 Sic Code Zone Act. # Zone Project No. 6 Dwell # 1 No. of Buildings t Sq. Ft. /Acre Depth 1 4Co Frontage c� 7 Set Back -Front (L)S -1 0 y (R)S -2 Rear census Tract Module No. Initials 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) 11Contractor Firm Name 1V1'� Street Address Zip City State Phone ( ) Contact Person License No. Phone if different than above ( ) 8 Owner /Agent (if different than #1 above) ern& Business Address 9 Zip City State Phone 12 Review Required Plan Check (Y /N) ; Other (Y /N) Jam. SEPA Exempt (YIN) Date 15 Type Work `G Bldg ❑ Fire ❑ MH ❑ Demo d t i+ Add /Alter El Replace ❑ Move ❑ Other 14 Describe Work Do 1T( 4!'4 loci c t,.., iv 1 P.4 --resectra. 10 Applicant Name Street Address 1 Zip City State Phone ( ) 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 ❑ Commercial; 4esidential W. 1101 College ❑ New Construction; ldg alteration /addition Room 200 ❑ Additional structure; Release Release w /cond 1 Hold 2 /l r APPLICATION # Conditions /Comments• Planning /Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage; N. 721 Jefferson ❑ Setbacks; ❑ lot w /d; ❑ lot size; ❑ use /zone; ❑ CU, variance, zone change; shoreline; ❑ fence; ❑ Other Conditions /Comments• Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; N. 811 Jefferson ❑ drainage ❑ new access /approach; ❑ fence; El 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 1 Indicate above or attach conditions relative to final as built approval 2 Indicate above or attach reasons for hold Scale 1" -- 20 Ft. Surveyea:..ay I hereby certify that I surveyed the above ncscribed property and that I find the improvements to be on the premises in question and that they do not encroach on the property lying adjacent thereto - I;XCi�PT: �n � r^ �' �Gr.•.J G1j • �rr�' PIIILIP L. SARGENT" registered Land Surveyor Phone FAirfax 5 -3664 4P NO improvements encroach on these premises — Except: OWNER or BUYER L?r 7 ■ t! I 1' \ R-?Di 1 ' ti Vi � . t 136. o' I 7 ($.0' 36. 8'