1984, 12-11 Permit App: 00003700 Extend Deck Roof_ 0og 2
BUILDING 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) 1, ir(first)) (m)
I' I -• i4 el KI I /Ta in /to •�T� �^
Department Use Only
Rte. Comm
2 Project Address (not Mailing Address) a -Road Name Space Zip
4 /872-/ Gibcee. CL.
3 City/Community
Otis G{#ctia ids
State
rev r4
Subdivision/ Plat Name
114—f rr i
4 Assessor Parcel No
66g rc2 — /s-73
Lot
Block
. t + DEPARTMENT USE ONLY *
5 Sic Cade
Zone Act.* -
Zone Project No
6 Dwell*
No. of Buildings
Sp Ft./Acre
Depth
Frontage
7 Set Back -Front IIL15-1
II
(R)S2 (Rear
Census Tract I Module No.
Initials
16 Architect Firm Name I Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Contractor Firm Name
Cn ti4-5Co. f v✓G
Street
/Ij5-a
Address
/G fJoskc y1-
Zip
°/9267'
City
S1od to eve_
State
GVX/
Phone
( ) 477 3C 9,G
Contact Person
JrPin M4 ran ;,40.-i
License No.
60ut-SC7J75 ,ei
Phone If different than above
( )
8 Owner/Agent (If different than #1 above)
Business
Address
9 Zip -
City
State
Phone
1 1
12 Review Required
Plan Check (Y/I4)
Other (Y/ N) 1SEPA Exempt
(Y/N)
Date
15 Type Work )c Bldg
0 Fire
0 MH
0 Demo
0 New
7 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
5)(/c s1 rJ 0 c4 ry r?M-4 /I/M re, L,YS,,f -1.S
-estiry DEe(
10 Applicant Name -
I Street
Address
11 Zip ,
City
State
Phone
f )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
I )
Additional information