1984, 07-24 Permit App: 00001344 Wood StoveBUILDING 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) o Iml
Department Use Only
�j �✓
Comm
es
2 Project Address not Mailing Address) Nl/`I`''__// me Space Zip
/005://1, LocoSD' 9W oG
3 Gty/Community
,S � C(.✓t e
State
/�/�l//JJ
Subdivision/ Subdl n/Plat Name -r op
17/ idc��j�l CA
4 Assessor No_ / ( Q 71,
5(ne, I l/I/
l V
Lot
Block
* * * DEPARTMENT USE ONLY t a t
5 Sic Coda
Zone Act.N
Zone la.
Project No. 1 3
"'�
4.
8 Dwell #
No. of Buildings
IL
Sq Ft /Acre
depth
c
Frontage
I7 Set Back -Front i 015-1
(R)S-2 I Rear
Census Tract I Module No.
Initials
18 Architect Firm Name (92�
Ow .e✓ Streat Addressss
Zip
City
State
Phone
Contact Person
Phone if different than above
( )
Contractor Firm Name
0,l,r,e ✓
Street
Address'
Zip
City
Slate
Phone
, Contact Person
License No.
Phone If different than above
8 Owner/Agent (If different than #1 above)
Bus'
ess Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check (Y/N)
Other (V/N) JSEPA Exempt
(Yl N)
Dale
15 Type Work 7siC
0
Bldg
Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
D Move
0 Other
14 Describe Work
I
10 Applicant Name /
< cu
IR:(e-7 y
Street
Address
UOS [/I LoGusd-
11 Zip
�9�0�olea,�e
Clty /
State
ls�,
Phone
(91) 9at/- 0//6/9
Lender
Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone if different than above
1 )
Additional Information
I
NStg: Cise'MWLnn 16 A 4-o 'glu)
Application Type
(Standard unless
otherwise indicated)
Fast Track
arly Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit Issuance.)
Environmental Health 0 Commercial; Residential
W. 1101 College 0 Construction; 0 Bldg alteration/addition
Room 200 Additional structure;
APPLICATION #
Release
Release
w/cond 1
Hold 2
Conditions/Comments.
Planning/Zoning: ❑ Comercial;
N. 721 Jefferson .Smetbacks;
❑ CU, variance, zone change; shoreline;
❑ ether
❑ Cert. of Exemption; 0 Frontage;
0 lot w/d; 0 lot size; 0 use/zone;
0 fence;
Conditions/ Commatrt s
1).17;2V -eV
AC — /
0
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions /Comments'
0
Utilities:
N. 811 Jefferson
Conditions/Comments •
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach condltlons relative to final as built approval
2 Indicate above or attach reasons for hold
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