HomeMy WebLinkAbout1985, 02-13 Permit App: 00004173 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
286 9-°
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 Qrmer's Na (last) (first) (m) Department Use Only
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/ 0 Ct, n) / l c' t_ v P ri f (-1 C�17 Fis. Comm
I
2' .Project Addreeb (not Ming Address) or Road Name Space Zip
Jay/7 E' i3uakee_
3 City/Community
.S�elActize_
State
LL)ce_
Subdivision/Plat
Fa)
Name /
cc & :/ o,fiec T 4t5 ,
4 Assessor Parcel No.
O 7
0 q .5-/Z — / -C-6
LotBlock
7
* * * DEPARTMENT USE ONLY * * *
r 5 Sic Code
Zone Act. k
Zone 3 6.,S 042)
Project No. ..,......./,--.13
6 Dwell4
I
No. of Buildings
1
Sq. Ft./Acre
Depth
I4o`
Frontage
00 I
7 Set Back -Front
30'
(L)S-1
_
(R)S-2
to'
t Rear
{I
Census Tract
I Module No.
Initials m
.10N
16 Archf Finn Name
CI ^^
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Street Address
Zip \.)
City
/�r^ �� /-
State
&e .
Phone
( )
Contact Person_
Na / a) Elm ,�1� _
Phone if different than above
may) -5/d 7 -- , e
Contr for Firm Name
/f eek ,eci,` a ...-3
Street Address
�J
f/a7s /.�%7/
Zip
,?92t 7
City
5o ,katze
State
WI_
Phone
(0e),) i'g 7--7zs2 _
Contact Person
get /V11cWan�a e
License No.
�'g6.s, -x.31„;0
Phone if different than above
( )
8 Owner/Agent (if different than 41 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) 1 SEPA Exempt (YIN)
Date
15 Type Work 71- Bldg
❑ Fire
❑ MH
❑ Demo
CA New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
1L
(� SC/5
10 Applicant Name J
W4 %iCYGt t tees' €_
Street Address
.dc'//2.3i2/
11 Zip
97L c9 r
Cit
0/0�' A.arztr
State
1
Phone �� -7_,7,2 D�
( )
ends ///j /X
Street Address
-Zip
City
State
Phone
Contac rson
Phone if different than above
)
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c7--1 # i4 ) 3 e /L et._(
Additional Information
M P .• 1O/� i \1 :'
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DEPARTMENT APPROVALS
1
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)
Fast Track
Early Start
1 IIID IJ IIVI A rui IluIt
(Indicated approvals required In either "release" or "release with conditions"
issuance.)
space prior to permit
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
ale/
Room 200 ❑ Additional structure;
APPLICATION # 05;007 7,
,�
Conditions/Comments: A Pe 2- uP-C-- P5 -pi 01 tJGT.F.I. l (-froL.
❑
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
0 lot w/d; ❑ lot size; 0 use/zone;
N. 721 Jefferson 0 Setbacks;
❑ CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments:
f
pji
I
a
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
,
N. 811 Jefferson 0 drainage new access/approach; 0 fence;
0 road improvements _
Conditions/Comments• "'WA — 0 0
i1
❑
Utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
y
Plan Exam
,72 -iii -Y
Fire Prev.
/24
Conditions/Comments:
Project Representative Telephone
....11., ,rte
1 Information
Agencies Performing Special Inspection:
1.
2
3.
1
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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N
1
12
rice c 141d4p
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