1984, 11-14 Permit App: 00003345 MH0g5s2,-oio3
-080)
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)
ner'sN (I t)
2 Project Address (not Mailing Address) m Road Name
N ZG /CJ J9,twyt4nc.,,X ,g j .
3 City/Community State
(first) (m I Department Use Only
Comm
Space Zip 6 L1
Subdivision/Plat Name
A1LC& W > Maine bitithre4 for
4 Assessor Parcel No.
Opc`2_-0002- _
5 Sic Code
Zone Act. p
Lot
.2 -
Block
* * * DEPARTMENT USE ONLY * * *
Zone
Project No.
6 Dwell N
No. of Buildings
7 Set Back -Front
\S-1
(R)S-2
Sq.
I Rear Census Tract
Ft./Acre
Depth
Frontage
Module No.
Initials
16 Architect Firm Name 1 Street Address
Zip
Cay
Slate
Phone
)
Contact Person
Phone if different than above
)
Contractor Firm Name
Street Address
Zip
City State
Phone
Contact Person
License No.
Phone If different than above '
)
8 Owner/Agent (I1 different than 41 above)
Business Address
9 Zip
City
State
Phone
• J ° ) 5" 2J 7
12 Review Required
Plan Check (YIN)
Other (YIN) I SERA Exempt (Y/ N)
Date
15 Type Work
❑ Bldg
❑ Fire
MH
❑ Demo
❑' New
0 Add/Alter
O Replace
❑ Move
0 Other
14 Describe Work
1-4 X-7? 0we'vve HimF_
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
l P tiA(-F-- /2 5 I