1985, 07-03 Permit App: 00006321 Residence•
06
BUILDING PERMIT APPLICATION WORKSHEET 237'
_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) (m)
avert Only
Inc(first)
n .,'"R�''j LL.i /d•irnr'. I-
Rae. Comm
2 Project Address (not Mailing Address) or RoaylName Space Zip
SuoI g. Besk
3 City/Community
" tO kan e.
State
WPI •
Subdivision/Plat Name��jj ,n
S4✓Cr_n n __ e "'o rr'•35 ,�
4 As>f4ssor Parcel No.
3S6 41.3-- 42.32'3
Lot
.�
Block
/
• • • DEPARTMENT USE ONLY * * •
5 Sic Code
Zone Act. 0
Zone
��
Project No.
682/
6 Dwell
/
No. of Buildings
/
Sq. Ft./Acre
/SycA5-v
Depth
. 0 r
Frontage
95-
7 Set Back -Front (L 8-1
3316"
(R)S-2Census Rear
37' 9i
Tract
Module No.
Initials
aKcd
r 16 Architect Firm Name • Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
Contractor Firm Name
Same c.s C-6 ✓N
Street
it,io
Address
it 6 k f
Zip City
�19dob oK4-n e
St/ate
I Gvn •
Phone
( ) 1026 -07ss
Contact Person
1e,661 r• S..Ja__ n SO n
License No.
pct - SlL -T
- /:3
Phone if different than above
( ) 9;26 -07.5-5-
8 Owner/Agent (if different than 01 above)
Busi
ess Address
9 Zip
City
State
Phone
( )
12 Review Required
PlanCheck (Y/N)
Other (YIN)
SEPA
Exempt
(Y/N)
Date
15 Type Work e' Bldg
0 Fire
❑ MH
0 Demo
X New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
Ids f OE►vCE
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 =e. 11
pi
SS9 = NC IUl JUL 3 1985
521 22F II \nn`F—CEIVEJ
52/=us' ��
DEPARTMENT APPROVALS
•
II
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
/
1 nis.is nota Permit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
wlcondl
Hold
CJI
Environmental Health ❑ Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200. 0 Additional structure;
�f%c
• APPLICATION # 1� v ` a
/
Conditions/Comments b. -x.. t c_1, z?G•Gf-((L
7 ,
rein,
•
Planning/zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑use/zone'
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence;
i
Z�
0 road improvements
Conditions/Comments `"ic- y/g
•
Utilities: •
N.811 Jefferson
Conditions/Comments
•
Other: _
-, r
Y
0
Plan Exam7_5
;2'y
Fire Prev.
�j�
��i
Conditions/Comments
Project Representative- Telephone
0
Agencies Performing Special Inspection:
1
E
0
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
• . •v. 3 (Ls r
•
.3, e
Ac_ic 4ari.
75--6 -7756
' 55-68 /5-#0,
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