1986, 07-08 Permit App: 00012137 Enclose Patio(THIS IS NOTA PERMIT) ,5g in /0
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
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Project Number tZ/5y
Owner's Name LAST FIRST r/ CA -1 MI
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Protect Address (Street Name/� &� Number) // Zip
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Address
City
Zip
Phone
(Saq ) 72k—G•s-6
Business Phone
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Contracto - •gent
Address
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city
State
Zip
Phone
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Contact
License Number (Required)
Business Phone
Architect/Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
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Lender
Address
City •
State
Zip
Phone
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Describe Work :_ .r:'S;ipn:, -_ _-tS3to-.n-.•. - ..: 2.na 'sS:'Res.".,
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DEPARTMENTAL REVIEW
/Environmental Health
R" W.•1101 College
Room 200
Application # `
Cond.
Approve. Approval
•
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
O N. 811 Jefferson
Utilities
0 N. 811 Jefferson
Plan Review/ Fire Prevention
❑ N.811 Jefferson
0
Other (SERA/ Critical Material /etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
1 certify that I have examined this application and state that the Information contained in it and submitted
by m : my agent to compile said application is true and correct.
Signature 'fs ,t/ r-cSrJ Date 774G
Showon Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants .
Structure Setbacks Topography
Easements Lighting
Septic System(s) Signage
Water Lines Shorelines
Sewer Lines Highwater Mark
1 Fences,Wells
1 Driveway(s)
1 Right of Way Width(s)
1 Names of
Fronting Street
Flanking Street
Legal Description 1
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Date:
Revisions: Attachments:
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