1984, 06-01 Permit App: 00000430 CarportBUILDING PERMITAPPLICATION 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)
pl1SEN0 �C..�NIv
pepertment J/!e Only
F. �/
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
G. ►Sa141 1342-0 A a .ov a Q0t2lCa,
3 City/Community
I<A
State
Subdivision/Plat Name
F (1 M/ MA p rlvo2 4-"
4 Assessor Parcel No.
/ �„ OaQa
Lot
Block
1 * * * DEPARTMENT USE ONLY it* *
5 Sic Code
tone Act. #
Zone Project No.
�
1' 111 0
6 Dwell if
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bade -Front
(L)S-1
(R)S-2
I Rear
Census Tract
Module No.
�rtlttdsl
16 Architect Firm Name
I Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
CityI
State
Phone
( )
Contact Person
License No.
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
/ChecJc (YIN)
Other (GY/N) I SEPA Exempt (Y/N)
G
Date
15 Type Work /Bldg
❑ Fire
❑ MH
❑ Demo
❑S New
V Add/Alter
17 Replace
El Move
❑ Other
14 Describe Work
C &R ?t CST A DO r Tc oN `2 2- X
1
1 7
I
10 Applicant Name
L S le-cGL.e R,
Street Address
E- l GodoS '�72,ca 0 141/4) a
11 Zip
Q'Zle
City
State
Phone
(-537) q7 --i- - (,(a IS
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
c m416
_ . 7- -7 4 V 0
C4 0- 10'17 / 2 s
I
DEPARTMENT APPROVALS
❑❑ 1
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis Is not a rermlt
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
Jr
!' �
5
i%_ 8
APPLICATION #
Conditions/Comments.
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments.
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new 0 fence;
I
I
access/approach;
0 road improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments;
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments.
' Information ❑
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
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