1985, 06-03 Permit App: 00005571 DuplexBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name
(Please return this original and your building plans to the Department of Building and Safety)
2 PromoAddress Mot Mailing Address) aHoaam
21 Z / ' . /54,Vr Z
Space
1 Department Use Only
phis
Zip
Comm
3 Gly/Commul I
SUMlvleiOn l Plat Name
4 AressOroel No _2
(LIS U5
Lot
5 SlcCnde
Zone Act. «
Zone
Block
As
• DEPARTMENT USE ONLY *
Project No.
S57I
6 Dwellx
No. of Buildings
Sq. FI./Acre
Depth
Frontage
)2()
] Set Back -Front
(L)S-1
(RIS -2
1h
Rear
Census Tract
Module No.
Initials
16 Architect firm Name
cr
It Street Address
Zip
Gty
State
Phone
Contact Person
Cony g F Nam c-4--›/144 , / H
Phone 11 different han above
Street Address _
2 -
(ere
,
(ere ) ?/{s
State
U
Phone
(76
- 32
Phone If different than above
8 OwnerlAgent ill mnerentthan 41 above)
9 Zip
1
City .'?1-E
Sate
Business Address
Phone
12 Review Required
Pla Check (YIN)
Oth r(YIN)
ISEPA Ekempl (YIN)
Date
15 Type Work
.1- Bldg
rl Etre
MM
Demo
Vf New
77 Add/ Alter
Replace
Move
C other
W Describe Work
10 Applicant Name
Street Address
11 Zip
City
Slate
Phone
Lender
Street Address
Zlp
City
State
Phone
(
Contact Person
Phone If different than above
J
Additional information
1l — L ) ,J
=
51)0 /IC IS
X2 = j32b
9
v
iii
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
F. Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION # Ci-- _x 0-04
r -2e -€J
Conditions/Comments:
Planning/Zoning: ❑ Commercial; C Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; C lot w/d; ❑ lot size; ❑ use/zone;
C CU, variance, zone change; shoreline; C fence;
❑ Other
Condit Ions / Comments'
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson C drainage ❑ new access/approach;
❑ road improvements
Gond( flans / Comments'
1 , nfr�.-! '-V--O lA. act k
❑ Flood Plal
❑ fence;
Utilities:
N.811 Jefferson
Conditions /Comments'
Other:
Plan E
Fire Pr
am
Release
w/cond 1
Hold 2
�Reeleease
Na
/7 E
r -2e -€J
Conditions/Comments:
Planning/Zoning: ❑ Commercial; C Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; C lot w/d; ❑ lot size; ❑ use/zone;
C CU, variance, zone change; shoreline; C fence;
❑ Other
Condit Ions / Comments'
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson C drainage ❑ new access/approach;
❑ road improvements
Gond( flans / Comments'
1 , nfr�.-! '-V--O lA. act k
❑ Flood Plal
❑ fence;
Utilities:
N.811 Jefferson
Conditions /Comments'
Other:
Plan E
Fire Pr
am
5-023-S-5--
-23-S-5(C'd
/7 E
Conditions/Comments'
❑
a p
E
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indkate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold
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5 �y
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