1984, 11-05 Permit App: 00003196 Demo Residenceta:
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 c» er ss Name +�/ [� �Oaastt) —••� �/+\ (first) /� t, (m)
/r/L `CK -f1 S/a€ //G •` �Co ,4.so7
Department lke9nly
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Comm
2 Pro)ect (uidress( MeiMM Address) Name 1 $ Zip
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3 City/Community
State
Subdivision /Plat Name
4 Assessor Parcel yyoo
r•
sovimak - lq,38
Lot
Block
♦ x + DEPARTMENTUSEONLY
5 Slc Code
Zone Act. M•7
Zone Project No. ,//fh80
6 Dwell t
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bads -Front IIL S-1
(R)S-2
Rear
census Tract I Module No.
Initials
16 Architect Firm Name Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
- Contractor Elan Name �
l/If/e�d- /O[MRi4seJr
��
StreetAddress
7.0 • gX 11 SS3
ZI
_7Zl(
City
.fold._
State
ca
Phone
(209) 9Z2 -2.3 `%3
Contact Person ;1'
License No.
Phone If different than above
8 Owner/Agent (if different than N1 above)
Business Address
9 Zip
City
State
Phone
( )
12 • Review Required
Plan Check (Y/N)
Other (Y/N) I SEPA Exempt (VIN)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
❑ Ot{(e11
JTh.
(t/j(///� /s'_-
14 Describe Work
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 lnformat� Iglt.� 57,..