1985, 05-13 Permit App: 00005378 Swimming Pool•
BUILDING PERMIT APPLICATION WORKSHEET
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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 Owners Name '//' (last) ) (first) (m)
-! NE1JtQN �Ei(/P/Li- G
Department Use Only
�. Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
./f) 7/9 ghat/641 a. 992'd
m+munity
3 Clty/Co/un
Statete/��/
Subdivision/ Plat Name
4 Assavor Parcel No.
—j
I d i 2 Y _^ 9 0 b G
Lot
Black
r f # DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act.. 0
Zone
Project No
6 Dwell 0
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bak -Front I6LIS-1
(R)S-2
Census nsus Tract _
Module No.
Initials
16 Architect Firm Name . Street Address
Zip
Clty
State
Phone
( )
Contact Person
Phone if different than above
( )
tractor Firm Name
AAt/.Jog4----Jaie.
Street Address
a-3rte)' aCere'ed
7.9%I6
City ��
Stet�,_
Phone
SW7) pet- .
Ota �ar04At
ail �Vi. CV°
Phone different than above
8 Owner/Agent (if different than 11 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (YIN)
Other(V/N) ISEPA Exempt (YIN) Late
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
Other
rionestMi Me
14 Describe Work
SGk%ImMIN 1900 .
10 Applicant Name
Street Address
11 Zip
City
State
Phone
1 1
Lender
Street Address
Zip
Clty
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 nota Permit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
O Commercial;
O New Construction;
O Additional structure;
❑ Residential
O Bldg alteration /addition
APPLICATION #
Conditions/Comments'
Planning/Zoning:
N. 721 Jefferson
.%n Fri r -
Release
Release
w/con. '
Hold 2
5 -, 5-75
❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone'
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
Engineers:
N. 811 Jefferson
❑ Commercial; 0 Residential; 0 Flood Plain;
❑ drainage 0 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
i/9 61 sad
9zy- 9833