1984, 07-16 Permit App: 00001196 Residencei3 -z g
If, 7S- 4S-
BUILDING 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)
v CL 4 p A -P- 4 (i 0 e iti < -(--- O-- AI
L 4
Depart mennly
Res. Comm
2 Project Address (not Mailing Address) cc Road Name Space Zip
A. ,/c 6 /Li - ec)di+
3 City/Community
GRQ - e,,I 4 -C e c (
State
ia) A.
Subdivision /P t a e • J .+
'' - - -- .1,00 rico
4 Assessor Parcel No.
t1
IS 5 5 - -.319` n&
Lot
/
IO
Block
( + * + DEPARTMENT USE ONLY * * *
,, 5 Sic Code
Zone Act. #
Zone Project No.
6 Dwell #
N
No. of Buildings
Sq. Ft. /Acre
Depth, (
J "7
Frontage }
155
7 Set Back-Front
1
(L)S -1
(R)S -2 i
/0
I Rear
Census Tract
1 Module No.
I nitiajs ( )
- V
16 Architect Firm Name
0k.fC- t-r:mot d' (,s Li
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
(Contractor Firm Name
f
( /Lt tLp 4,', ._ (( 0/O /IX4 i 4/ e
Street Address
S. 3cio ll / i)43. (r, 4 l c
Zip
c r g o c
City
_0 K4-Al -0
State
t ;.4-
Phone
(5-('I ) q e2-4-( -5� S -7
Contact Person
/12 / /,(e t,6C16(b } 4.0 ,^-
License No.
i^ - R P- A C - e I.-- 7S1. .S
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 (Y /N)
SEPA Exempt (YIN)
Date
15 Type Work , Bldg
❑ Fire
❑ MH
❑ Demo
< New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work fr?) _,,. P j-
��AV�
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
1)n ,i_ a _ C/1 �f
z /}
lY�n'
24 .?c Z1
P - 8 .4(o
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;
APPLICATION #
❑ Residential
❑ Bldg alteration /addition
r--
Release
Release
w /cond 1
Hold 2
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;
N. 811 Jefferson ❑ drainage ❑ new access /approach;
❑ road improvements
Conditions /Comments•
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions /Comments•
704'
1
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
t41L -1-" P vc
ASTM D4o3'/
5P/4 35 Z
1214-4-
-?,
1" WAT EK
METEK
N`. if 06 » e L, C► o 0--
24-x2.4 -
6AR46e.1)
-VS"
;of 281
L. or 6) 15PtGoIJS Abt,t-J To
o%.AckIE co-, WA_
I r _
X11 40I -11
IPA
80 I'RI M MR.Y
I oo 6.ONtA '(
brAIt•FIELf
fl
tJN
N
- I7I 'T. 150*
EPTIG TANK
EMEIJT