1985, 05-23 Permit App: 00005555 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)
1 Owner's,Name (last) (first) (m) DepartmentyeOnly
✓
l
/ ` i /$,k (0,, rim v �' 770 -TJ /"\: C . Cd/IU C e 114 pi r741 S 1143s. Comm
2 Project Address (not Mailing Address) ar Road Name Space Zip
ET78/3 64-04ss X.2/2
3 City/Community
State
Subdivision/Plat Name
5 ye."' - o ii�i77�
4 Assessor Parcel No.
o , C Y 3_ 4S,3
Lot
3
Block
/
* * * DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act.*
Zone ,4 u
sth
Project No. 5 / /
✓�
6 Dwell*
/
No. of Buildings
/
Sq. Ft./Acre
Depth
/56
Frontage
76
7 Set Back -.5
(L �6,
(R)S-/ G l
Rear
Census Tract
Module No.
Initial t ,
cii
16 Architect Firm Name
...D...±1-7-1-• -)N G if b e s / G,V
Street Address
iv �e.C / / ti, Sn/ ak ,
Zip
� 20
City
�i-)v/C14'+L—
State
1A /4-
Phone
(5-v5) Y83- 76,00
Contact Person
J -C ----F- S0.0,P_2 ti' (s-
Phone If different than above
( )
Contrac�t°Q Fir Name _�
K 0.60 t eos,sr)Qee!7706/ AJ(,
Street Address
Pe /�G
Zip
9 2 i ti
City
Siolc•eirl
State
GL„ ,
Phone
( col) 92 7-Z/ 2/
Cont Person
%duce �'tl f $
License No.
RcB✓v�Cz + l 7SQQQ
Phone if different than above
( b) 41/76- 90? 2_
8 Owner/Agent (if different than *1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (YIN)
Date
15 Type Work Pf Bldg
❑ Fire
❑ MH
❑ Demo
'New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work _ k,
St
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lend
C.0-viv, 4,/4 i:.-_
Street Address
A/ Sri- A26cavibe
Zip
q1 Zvi
City
.._)ilt,4-1,1P
State
k-
Phone
( 569) 92 2 •-/z6c,
Contact Pe son
.kLI t4 -4•J Sem r•.,/
Phone if different than above
( )
Additional Information
PIA -Ns APPcJFcJ he/ 0M3-- 03//2`F5
M r - WO r r -c K - ,-O
Ce P _ FE,/
DEPARTMENT APPROVALS
L ❑❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health 0 Commercial; ❑ Residential
W. 1101 College ❑ New Construction; 0 Bldg alteration/addition
Room 200 ❑ Additional s ucture;
'(
rj
APPLICATION # 1 6)
C4 . . / . y .. a �, - i '�/� J - ll9►, a� ;�
/ll
i1/ 7iitc !%v'1LaCan{ImrlyJ,"� lfi/,'rgezdarll/_L'ret•1ri,�:.
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
ill
Engineers: ❑ Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
S7
0 road improvements
Conditie{ om
* i ---}-}P
Utilities:
N. 811 Jefferson
Conditions/Comments•
•
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments:
IInformation ❑I
Project 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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