1985, 02-22 Permit App: 00004270 Addition• °;. ' 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)
HJ7111-s - J17 -n
2 Project Address (not Mailing Address) -Cr Road Name
870 3 G 1-07/ AZ.
3 City/Community
4 Assessor Parcel No.
lTrelif l // r
5 Sic Code
6 Derek*
Zone Act. N
No of Buildings
Lot
Zone
State
w �
(m)
Space
IDepartment Use Only
Res.
Comm
Subdivision/Plat Name )
kin!?INoTDNS �l313 `N WI -C INSori
Block
Z
b
Sq. Ft./Acre
* t * DEPARTMENT USE ONLY * *
Project No. 4/2:72)
Depth
14f
Frontage /
(2S •08
7 Set Back -Front
;✓X 15T1 n1 G
(L S-1
(R)S-2
Rear
Census Tract
Module No
Ini 1815
Ju ni M •
16 Architect Firm Name
Street Address
Zip
City
State
Phone
1 )
Contact Person
Phone if different than above
Contractor Firm Name
Street Address
Zip
City
I State
Phone
1 )
Contact Person
License No.
Phone 11 different than above
8 Owner/Agent (if different than P1 above)
Susi ass Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N)
Other (Y/N)
ISEPA Exempt (Y/N)
Date
15 Type Work
)9. Bldg
0 Fire
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
❑ Move
0 Other
14 Describe Work
S`fb.12PrE PrPDITloM
.10 Applicant Name -
J/lz/tfe' /3 tD/7/15
Street Address
( U• (OA (j375
11 Zip
q
City
S,
State
L✓A
Phone
17) /7S3
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
1 )
Additional Information
DEPARTMENT APPROVALS
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
This Is nota Permit - z,. -
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit Issuance.)
Release
Release
wlcond 1
-
Hold 2
Environmental Health ❑ Commercial; . - 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration /addition
Room 200 0 Additional structure; - -
c'— _1 �
A�'
r
'
APPLICATION #
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 drainage 0 new 0 fence;
access/approach;
❑ road improvements
Conditions/Comments' - - -
•
Utilities: . .
N. 811 Jefferson
Conditions/Comments'
El
Other:
Plan Exam
Fire Prev.
Conditions /Comments..
Information ❑I
Protect 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
14
Ql,e 30 —
d_
A
5TartA6E
4 1 N