1984, 11-15 Permit App: 00003624 MH6`1 r41 — -071
BUILDING PERMITAPPLIGATION 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 .,L (last)
NA 11t0il/
C(first)
GS E
(m)
I�•
Department Use Only
�. Comm
2 Project Address in Mailing Addr7) a Road Name
ACE
Space
e-
Zip
99g06
3 City/ munity'
S b K
State
V)A s fi/
Subdivision/Plat Name
a act s S 9 -ass
y�
4 Assessor Parcel No.
^ s -L2 _ 0-70b,
"l_:v"
Lot "Block -
'` L �t t t' DEPARTMENT USE ONLY t t
`2
t
5 Slc Code
Zone AcLs ' `„ -
Zone •„ ?
Profect Not •• ,;" -
/LDepth
6 Dwell#
%i
No. of Buildings
r
-
Z
Sq. FtJ Acre
' I +
I "'310 —
Frontage
[ 3' 2
t
7 Set Bak -Front (L)S-1 172
Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
Stale
Phone
1 )
Confect Person
Phone if different than above
Contractor Firm Name
Street Address
Zip
Gty
State
Phone
1 )
Contact Person
License No
Phone If different than above
8 Owner/Agent(it different than sl above)
i
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check(Y/N)
Other(Y/N)
SEP
A Exempt(YIN)
Date
15 Type Work - ❑ Bldg
❑ Fire
pl--MH
❑ Demo
❑ New
❑ Add/Aller
❑ Replace
❑ Move
❑ Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City
State
Phone
1 5by 1 y3 y- oo 79 -
Lender
Street Address
Zip
City
Stale
Phone
1 )
Contact Person
Phone if different than above
1 )
Additional Information
DEPARTMENT APPROVALS
c
-
This is not a Permit
Application Type
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release- or "release with conditions"
space prior to permit issuance.)
❑
Early Start
Release
of
U
Environmental Health
W. 1101 College
Room 200
Release w/cond 1 Hold 2
❑ Commercial; ❑ Residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION p
Conditions/Cpm menta:
t�'nLwLet
❑
Planning/Zoning:
n6t
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage; P'
N. 721 Jefferson
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; 0-31-g�
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
c -,O — �7 —
❑
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson
❑ drainage ❑ new access/ approach; ❑ fence;
❑ road improvements
Conditions/ Comments:
❑
Utilities:
N. 811 Jefferson
Conditions/ Comments:
Other:
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
i
Project Representative
Telephone
Agencies Performing Special Inspection:
c
O
1.
E
o
2
C
3.—
.
Indicate above or attach conditions relative to final as built approval
Indicate above or attach reasons for hold
1
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