1984, 06-13 Permit App: 00000677 Covered Patio•
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) (first) (m)
pepariment/U�a Only
�i{ /+
��M1 / 5 fie ( e-,02
iLe. / Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
5 7 3 5/& ke 3.0 %
3 City/Community ✓
5,a/Cance_
State
1(2a-
Subdlvlsl0n/Plat Name
i Ln -t l,eyeR S' ht i is(on-c
4 Assmwr Parcel No.
J
035`1 1 _3 `OZ
Lot
2-
Block
?
\l
r w + DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act. If
'Zone
Project No. •
6 Dwell M
/
No. at Buildings
/
Sq Ft./Acre
Depth
i25
Frontage
go
• 7 Set Back -Front
(L S-1
(R)S-2 Rear
it
Census Tract (Module No.
Initials
16 Architect Firm Name Street Address
Zip
CIN
State
Phone
Contact Person
Phone if different than above
( )
Contractor Firm Name
5022 e
Street Address
Zip
City
State
Phone
( 1
Contact Person
License No.
Phone If different than above
( 1
8 Owner/Agent (if different than X1 above)
Busi ess Address
9 Zip
City
State
Phone
Review Required
P J /N)
EC12
Other Y(Y/Nc)— ISEPA Exe=pt(Y/N)
Date
15 Type Work Idg
0 Fire
❑ MH
0 Demo
0c New
X Add/Alter
0 Replace
0 Move
0 Other
14 Describe Wor
ATro ADO iTeo w — 1G k- a2
10 Applicant Name O //(��'���-
` J
Street
Address/,/
/31/G
31/G -e xe
11 Zip
992 /6
CIy4
City
5701<a -n -E
State
Gve-i.
Phone
(`r2•‘)57it' `T
Lender
Street Address
��,,���yy��
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information,
sZ - r 0_0o
X0"7 c ie.
DEPARTMENT APPROVALS
❑
9
Application Type
(Standard unless
otherwise indicated) -
Fast Track
Early Start
Inisisnor arermmt
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
L
Environmental Health ❑ Commercial; �
W. 1101 College 0 New Construction; tYBldg alteration/addition
Room 200 0 Additional structure;
1sidential 1 t
APP #
;TION
.
Plan li de
6 AL!:
ill
Conditions/Comments ��
a/• -
Ql - 11111111E1
•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; 0 lotw/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/ Comments-
•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new - 0 fence;
access/approach;
❑ road improvements
onditions/Comments-
Conditions/Comments-
El
❑
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
•
Plan Exam
Fire Prev. -
Conditions/Comments• -
IInformation ❑i
Protect Representative Telephone
Agencies Performing Special Inspection: -
1
2 1
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold -