1985, 04-22 Permit App: 00005045 AdditionBUILDING 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)
A!/�►
ir t- k "f"
Department I Y
Res. Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
9/7 tis//c, 92c6;..
3 City/Community
Statte�)
Subdivision/Plat Name
•tG f"• L
sfsyr) Parcel( .
4 r No.
(:)-73---V2_—c y — 1
a� l
Lot
3
f Block
I
. . . DEPARTMENT U E ONLY * * *
5 Sic Code
Zone Act. #
Zone
2
Project No.
5o g'
6 Dwell #No.
/
of Buildings Sq.
Ft./Acre
Depth
Frontage
i& e)
7 Set Back -Front
I (L)S)S 1
(R)S-2
Rear
(�nsus Tract
Module No.
Initial s
16 Ar itect Fir Name
0 -5 Bre.
Street Address
3�‘,7 s��.(fy?f
Zip
G
ilk oz_.
City
��"d �0
State
Lo l'4<
Phone
.6r ) ,5----,55--- 0,575
CoDPerson
6. //!.zJ€ L ri
Phone If different 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 Check (YIN)
Other (Y/N) ISERA Exempt (Y/N)
Date
15 Type Work I'Bldg
0 Fire
0 MH
0 Demo
11/New
0 Add/Alter
0 Replace
E Move
0 Other
14 Describe Work
/7.2e4 STne4a t- Biog_ No s/AB
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 not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
D Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
J
x_12 I
APPLICATION #
Conditions/Comments•
� U
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•
J
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions/ Comments•
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
El
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
wst.Ng
reS 1(/&'MC e
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