1985, 02-27 Permit App: 00004298 Garage54 -lire'
•
BUILDING 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)
1OOwner's Name �' (last) COfisst), ` (m)
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Department Use Only
Fes. Z� Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
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3 Gty/Community
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State
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Subdivision/ Plat / G
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4 AesYessorr Parcel Ni (I
Lot
//
Block
/ /
* * * DEPARTMENT USE ONLY * * *
//
7 i 4 G f. [ -eG
5 Sic Code
Zone Act. #
Zone
AG
Project No.
l C..!
6 Dwell #
I
No. of Buildings
1
Sq. Ft./Acre
Depth 1
(. S
Frontage I
16
7 Set Bads -Front
E Xl X1'1 NI
(L)S-1
51
(R)S-2
Rear
Census Tract
Module No.
Initials
J ti t ,nn .
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Fir Name
s-�1 a rf A 1.___
Street Address
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Zip
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Gty
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State
G-erGS- i ,
Phone
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(.3 e.'a /) l2 44" j
Contact Person �/
License No.
Phone If different than above
8 Owner/ t (if differen han #1 above)
((((((//////
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/ N)
Other (Y/ N) ISEPA Exempt (YIN)
Date
15 Type Work Bldg
0 Fire
D MH
0 Demo
0 New
K Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work t
A1TN P 6A f 29 ' X 21
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
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
Conditions/ Comments'
❑ Commercial;
❑ New Construction;
❑ Addition ructure;
APPLICATION # 3
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
At
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments•
El
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions/Comments•
❑ Flood Plain;
❑ fence;
El
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
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