1984, 11-21 Permit App: 00003466 Residence� a
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)
1 Owner's Name _ (last)(first) (m)
1Departmefl.OnIy
�'�� X1/11';S Fisa. , Comm
2oject ddre not Mallin rens ad Name Space Zip
119 31 D ipitiA a,..,,. -I- 99,20(,_
City/Community
k:9 e
WAS
Subdivision/Plat Name
MIT) C \AA 3r -_L �idr i tcri
4 Assessor Parcel No.
A 4 -9 On
'3
Lot
��
Bloc
* . . DEPARTMENT USE ONLY * * *
x..._.
!S
5 Sic Code
Zone Act. ff
Zone S Fe Project No. ikot,
6 Dwell #
/
No. of Buildings
1
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front /
(L)S-1
(R)S-2
,:25i
l Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Co2ntsactor Firm ge,u Na. e 12 � 1.1 /V'
ddress
Street 1 / /4114,..u41 i i �i -
Zip
13 3 1g7ictik-bvdee_
State
LOA sll.
Phone 1
(se) 3 --3S
Contact Person
keit.)�:
4
DEPARTMENT APPROVALS
•
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
1111) IJ Iilit Q rel wit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health Cl Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
—r[
'J I
Room 200 [1 Additional structure;
APPLICATI #
ll l C � t '
Conditions/Comments: _VI-
....)
Planning/Zoning: ❑ Commercial; C Cert. of Exemption; D Frontage;
❑ lot ld; ❑ lot size; ❑ use/zone;
N. 721 Jefferson ❑ Setbacks; w
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments:
0 Commercial; 0 Residential; 0 Flood Plain;
I/
•Engineers:
N. 811 Jefferson 0 drainage ❑ new accesslapproach; 0 fence;
❑ road improvements C
Conditions/Comments• !—�A — 6 >"
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Pian Exam
Fire Prev.
Conditions/Comments:
ry
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
Z,ex k. az
1/93/ 6-- DJ/f,0/i Co(/4
Aiece/z. 3 3c44 9 00,2
DIAN 11 C 0 (-$. ("11—