1985, 04-03 Permit App: 00004832 ResidenceBUILDING 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) li
1 Owner's Name
(last)�/1�(� `(m)
&,1e.II ek ety;irst) f4l s l i `moi 1 �,�
pspartment IJs�Only
fbs. A/
Comm
2 Project Address (not Mailing Addr Road Name Space Zip
\1110 a\c--&‘
3 Cly Community
)J�. V Pre
'
State
: LOPt
Subdivision/Plat Name
t- )A1 iz. ArLe_ES TZcmc_,A-r
._.
4 Assessor No.
1(3°5 544-2-J _ „Ac3 -F 1.-^-)
Lot
7—
Block
* * * DEPARTMENT USE ONLY * * *
Project No.
A..0 ,.... 2._
5 Sic Cade
tonn e Act. 4
Zone
Pk 6 ScAr,
6 Dwell 8
1
No. of Buildings
Sq. Ft./Acre
Depth
IC°
Frontage
—15
7 Set Bads-Front(L)S-1
j
(
(
(R)S-2 ,
2 ci
Rear
Census Tract
Module N
Is _-^
7y
16 Architect Firm Name
Street Address
Zip
City
State
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 (If different than 41 above)
() LA -41e pl nCke 11+
Business Address
9 Zip
City Q
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other (Y/N)
SEPA Exempt (YIN)
Date
15 Type Workdg
0 Fire
❑ MH
0 Demo
1:1..-ktew
0 Add/Alter
❑ Replace
0 Move
0 Other
14 Describe Work `
CDU61A11/41 Y1 -k-0tp
10 Applicant Name /
Street Addr n11
. ee s .
ZipC"
rt cD--I
Cit `
4, K _.1-1-,,,-)..0
State
�_ ` f R
Phone
( ) q 2, c2 9‘,-5
Lender
Street Address
Zip
City
State
Phone
( )
Conte rson Cox
Phone�above Q G� 2 �/
if differenterthan6-2---D-0'-
' () `'%r� 0'' /1 it 1 X )
Additional I oformatten
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ate, 3 _ -_ 1 i
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*
*
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health ❑ /commercial; ❑ Residential
W. 1101 College New Construction; n Bldg alteration/addition
Room 200 ❑ Additional structure;
Q� / QG/
APPLICATION # 0 �/J �f J
Conditions/Comments• /cam/ ( , 1 el (G' Y
i
Release
(,f_cj_i�
Release w/cond 1
Hold 2
(1/4,161 `
W,'`
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: ❑ Commercial; 0 esidential; 0 Flood Plain; IG
N. 811 Jefferson 0 drainage new access/approach; 0 fence;
O road improvements
Conditions/Comments• /��/c2
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
a
co
]
'Ian Exam
(,f_cj_i�
Fire Prev.
W,'`
Conditions/Comments•
Protect 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
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