1984, 10-01 Permit App: 00002575 ResidenceBUILDING 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)
_ne
4 , -G(/GS/--- /N G"
Dapartrtbnt flee ly
FS. IComm
2 'Project Address (not Mailing Address) or Road Name( Space Zip
.5 32/ A/. ,2t—sr 1Ti3,h.° , .,
3 City/Community
s/%51/C9.v--1
State
A4
Subdivision/Plat Name
5 - 2-2:927'
4 Assessor Parcel No.
RG&41-7
— ,8OT -
Lot
- - 7
Block
_ L /
idAcres
♦ . ♦ DEPARTMENT USEONLY
5 Sic Cade 1
Zone Act. M
Zone
R- i
Project No.
7-115.-
6 Dwell X
/
No. of Buildings -
i
Sq. Ft./Acre
/(o gob
Depth
/60
Frontage
/05
7 Set Back -Front (L S-1
'f% 20
(R)S-2 Rear
31 SI
Census Tract
Module No.
Initials
���
C v
16 Architect Firm Name - Street Address
%rz<o - - 52/2...47,1..E S'
Zip
City,
Ga SCI% c 1514 F49::
State
/%-
Phone ^
�
(Zo a^) / e- -- c.SJYO
Contact PeCrson
Phone If different than above
Contractor � Firmir/Name •
4/74/1141 -7•2.a- G�/GST/ /.(JG
Street Address
,,tro. /YS>d :S 77
Zip
afl./ ....
City
G%C .C/[/,40lL
State
- Ge -7,‘,1
Phone
(Sv74 % Z y - 4d ciJ 5
Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than p1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) I SEPA Exempt (V/ N)
Date
15 Type Work e Bldg
0 Fire
0 MH
0 Demo
5kNew
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
10 Applicant Name
ede ,Afr, rrr y ' /2 :' Com/ -( , 4. t, -v e /t//r//L-Te.
Street Address .
_5;9 /Y/.a
11 Zip
City
State
Phone
Lender
CG
, t rc,v17-14 X / rc72r e 2 c
Street Address
-
GO.5 - )W- - c>c-'�Z //-
Zip
9' *Z0/
City
ST�0.ks.rl..c"
State
--.
Phone
(Sal'? 328 -•Sod
Contact Person -
�Arzr�� 771044/9 5-177i r//
Phone If different than above
.( 1
Additional Information
co
C
a
a
co
U
N
M
co
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
(Standard unless
otherwise indicated)
This is nota Permit
(Indicated approvals required in either "release' or 'release with conditions"
space prior to permit issuance.)
•
Fast Track
Early Start
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;st
/
APPLLI%�II; TION # (7 `T /®/�D
,,�///
Conditions/ Comments •- : iii / ifXS
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot slze; 0 use/zone-
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions) Comments•
Engineers: 0 Commercial; : Re ' enlial; r Flood Plain;
N.811 Jefferson 0 drainage ew access/approach; 0 fence;
"rr',
.4
�"��
t.�,
0 ai�.rrlprove �p( 3
Conditions/Comments (� bt-' � O 474
Utilities:
N. 811 Jefferson
Conditions /Comments•
•
Other:
•
Plan Exam
/0^!'S
Fire Prev.
rte
onditions/Comments-
Conditions/Comments-
Project
Project Representative Telephone
Agencies Performing Special Inspection:
1
Informati
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
SPO U !E C 3 ,;T'e ?TEI LTh DISTRICT
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37'
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