1984, 10-15 Permit App: 00002860 Residencep BUILDING PERMIT APAL14,1-TION 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)
�� (.� �[SeS
% C
(first) Im)
Oapennient Lisa Only
�. Comm
2 Project Addr '(not Meiling Adddrree/i�*)"a Road Name
Sf A Ave,
Space Zip
3 Gry/Cam�/9,unity
StI
Subdivision/ Plat Name
-
d Assessor Parcel No.
67Og'
Lot
S-
Block
+ + + DEPARTMENT USE ONLY + +
Fr t9r+t�s
+
5 Sic Cade
Zone Act. N
ZonePVG?
Project No. �
6 Dwell N
No. of Buildings
Sq Ft./Acre
Depth 1
alb
Frontage Ij
c32
7 Set Bads -Front (L)S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
I
I
16 Architect Firm Name
Street Address
Zip
Gry
State
Phone
1 1
Contact Person
Phone if different than above
Contractor Firm Name
e4O5is��
Street Addreae
Zip'
City
State
Phone
Contact Person
License No.
D�-2-3 0
Cku s Z �S XN�
Phone If different than above
S Owner/Agent (if differepf than N1 above)
Business Address
g Zip
City
State
Phone
12 Review Required
Plan Check(V/N)(,
Other (/N) $EPA
Exempt(V/N)
Date
15 Type Work Bldg
O Fire
❑ MH
❑ Demo
New
❑ Addl Alter
❑ Replace
❑ Move
❑ Other
14 Desc`jJ,jo(@yWork
(orfu
10 Applicant Name
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
1 )
Additional Informatmn
1
3
06 = 18 710
3
OCT 1.) 484
1111
DEPA€R 1!k)ENT APPROVALS
I1 Indicate above or attach conditions relative to final as built approval
2 2 Indkate above or attach reasons for hold
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
I Release
Release w/cond 1 Hold 2
Environmental Health
W. 1101 College
Room 200
❑ ommercial; Residential
New Construction; ❑ Bldg alteration/addlt Ion
❑ Additional structure; '
(
APPLICATION 1f O I 1 S
Conditions/ Comments:
❑
Planning/Zoning:
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ uselzone;
+
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
Engineers:
❑ Commercial; ,f%sidentlal;
N. 811 Jefferson
!DFloo:dPlaln;
❑ drainage CJ new access/approach;
Conditions/Comments:
❑ road Improvements
Utilities:
N. 811 Jefferson
Conditions/ Comments:
Other:
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
c
0
1.
E
`o
2
`c
3.
I1 Indicate above or attach conditions relative to final as built approval
2 2 Indkate above or attach reasons for hold
0091'r -q
CROSBY
Realty