1985, 04-04 Permit App: 00004881 GarageBUILDING 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)
9rkc--k. 2K4
Department lhfeCnly
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
(09) s E Ce f,L,.s/e
3 City/Community
spo Ka Ne.
State
tVa-
Subdivision/ Plat Name
4 Assessor Parcel No.
6 y - ie .5-3 / - go 4%
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act.*
Zone .
Project No. ¥e ^ /
�j
6 Dwell ft
I
No. of Buildings
3
Sq. Ft./Acre
PS
Depth
3's'
Frontage
70'
7 SettBack-Front
—7C 1/I1(o
(L 5-1
I
(R)S-2
—_
Rear
..---J
Census Tract I Module No.
Initia'Is' f
V'V m .
16 Architect Firm Name Street Address
Zip
City .
State
Phone
Contact Person
Phone if different than above
( )
Contractor Firm Name
1"O4.77./ 14-CO1.4- v. -7A e t.‘ sfe.e. t Q\ci oy S
Street Address
£ 6 a/ s- mot- b,J
Zip
90,a06
City
5pok'o,A.,e
State
tJ0.-
Phone
(513g 1 63S90lb
Contact Person
Cht^e-li hidCohc•'(trjsO,
License No.
-/-0•w/1.) -Cs-131/o3SQf
Phone if different than above
( 1
8 Owner/Agent (if different than al above)
Business Address
9 Zip
City
State
Phone
( 1
12, Review Required
Plan Check (YIN)
Other (Y/ N)
I SEPA Exempt (YIN)
Date
15 Type Work fQ Bldg
0 Fire
❑ MH
0 Demo
New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work Q /+ Gt
Co NJ4 r h q.� OMC. 3010 A� X l a r-o.c .
10 Applicant Name
Street Address -
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone if different than above
Additional Information
y
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
This Is nota Permit
Application Type
(Standard unless
otherwise indicated)
(Indicated approvals required fn either "release" or "release with conditions"
space prior to permit issuance.)
•
Fast Track
Early Start
-
Release
Release
w/cond 1
Hold 2
E"
Environmental Health 0 Commercial; 0 Residential
W. Room1101 College 0 New Construction; 0 Bldg alteration/addition
200 ❑ Additional structs
��
,(,pr--�
()
�
APPLICATION # J
v
Conditions/Com ments•
•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑ use/zone'
0 CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments•
•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage - 0 new access/approach; 0 fence;
❑ road improvements
Conditions/ Comments •
❑
Utilities:
N. 811 Jefferson
Conditions/Comments•
•
Other:
•
Plan Exam
Fire Prev.
Conditions /Comments•
Project Representative Telephone
Agencies Performing Special Inspection:
1
IInformati
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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O S.. e4:o n. IQ No,t1;
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