1984, 06-12 Permit App: 00000644 Enclose Carporty
r
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)
ivagbea/ A7.
2 Project Address (not Mailing Address) o - Road Name c
3 City/Community
,j%/
4 Assessor Parcel Nale.5't _ 02.
Stat WA)
(m)
Comm
Space
Subdivlslon/Plat Name
. L v a14' Sc c . Aid.
Lot
Block
Zip
X90 37
* * * DEPARTMENT USE ONLY t *
5 Sic Cade
Zone Act. N
Zone
sFiam
Project No.
6 Drell
No. of Buildings
Sq. Ft./Acre
Depth if
1 ¢17
Frontage
,
7 Set Bads -Front
16 Architect Firm Name
(LIS -1
(RIS -2
Rear Census Tract
Module No.
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
)
Contractor Firm Name J
/12onR/s oN CQA)S
Zip
77...o 3
Street Address
ta?0 7> 33-Q. J
Gty
S00 km -N -e
License No.
Contact Person
8 Owner/Agent (if different than 41 above)
State
Phone
(so )-S xi 7/
//1 o.2 J( /93 . .
Phone If different than above
Al 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
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ Replace
❑ Move
Other,
CZyc i4.1 Crewe/
14 Describe Work %
CG 6 S /N 9 /1) C/oCYZ 7-D 74 C%a% 4 q`'p
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