1984, 09-25 Permit App: 00002496 PoolBUILDING 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', Name (m)
Department Use Only
Y& Roy(first)
Res. Comm •
2 Project Address (not Mailing Address) or Road Name Sp ` �y^ Zip
a: IAiU 1fPnta 7Y 7� f9vi6
3 Gry/CorBtnypO �
State
WI
Su ivision/P(aae
sat -,M�oR ISSD SP L-
4 Assessor
b
l No.
1 S -1 e2 -.Z31°33
i (/
Lot
Block
3
♦ t t DEPARTMENT USE ONLY ♦♦ *
5 Sic Code
Zone Act. If
ZoneProject
6r _/
No.
2.-A
6 Dwell MI
No. of Buildings
11
Sq. Ft./Acre
Depth 9.C. 1
l Frontage
4
7 Berl efi
06
(L)S-1
(R)S-2 j 4o
I
Tract
Module No.
InitlaIs
--1Census
0 0 .
16 Architect Firm Name I Street Address 1'
Zip
Gry
State
Phone
( 1
Contact Person
Phone If different than above
( 1
Contractor Firm Name
�s-ro-M Pao�s
Street Address
I n o K56, P Nis ,
ZiP /1 n -L-oto
City SPD
State '
V `
J
Phone ) F2-7—S-2-77
2� �177
Contact Per
a3 J w * 3 S 2s
License No.
Q.0 STt P Ito. MI .,i0
Phone if different than above
(-�=} '--
8 Owner/Agent (If different than 111 above)
Busi ess Address
9 Zip
City
State
Phone
( )
12 Review Required _
Plan Check (Y/N)
Other (Y/N) IISEPA Exempt (YIN)
Date
15 Type Work 0 Bldg
Fire
0 MH
0 Demo
X New
0 Add/Alter
0 Replace
0 Move
/yA�
fiX111eAltM t I V
WOrk
10 LA -1./
� �❑
Lb Iv Z&IJ ZaAst N‘IMtWit—
10 Ilwnt Name
Street Address
11 Zipamu?
Ser-
City
�S-/ adi �CtilV P--e-e-TOi-----
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone if different than above
A(‘-} Monet Information
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DEPARTMENT APPROVALS
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start.
t nus is nota rermit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
Rel i.
Release
w/cond
Hold 2
Environmental Health 0 Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
-
Room 200 0 Additional tructure;
7�
"!
/ I
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APPLICATION # - ✓" / 64_
Conditions/Comments
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/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 0 0 fence;
-drainage new access/approach;
❑ road improvements
Conditions/Comments
'
•
0
Utilities:
N. 811 Jefferson
Conditions/Comments•
ID
Other:
Plan Exam
Fire Prev.
Conditions/Comments. _ -
IInformation ❑
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
T 4 .
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