1984, 04-05 Permit App: 84A-3011 Addition GarageQ
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)
7-
(first)
(m)
Department
Only
Ras.
Comm
2
Project Address (not Mailing A
,F 5-1 4
ss) or Road Name
e//uc4,
Space
Zip
i�zi6
3
City/Community
S a n e,
State
I W
Subdivision/ Plat Name
'L,r4
SUN Nq V *'L'--
4
As6essor Parcel No.
I5p 1 I ®�
0154
Lot
Block
1r tr ,t DEPARTMENT USE ONLY * 1r
5
Sic Code
Zone Act. #
Zone
f 1-
Project
No.
6
Dwell #
No. of Buildings
Sq. Ft./ Acre
Depth
Frontage
7
Set Bads -Front
(L) (R)S-2
Rear
Census Tract
Module No.
Initials
16
Architect Firm Name
IV/ , '
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Contractor Firm Name
NJ X
Street Address
Zip
City
State
Phone
Contact Person
License No.
Phone if different than above
8
Owner/ Agent (if different than #1 above)
Business Address
9
Zip
City
State
Phone
12
Review Required
Plan Check (Y/ N)
Other (Y/N) SEPA
Exempt��(rrY/N)
?ILD
Date
15
Type Work
Bidg
❑ Fire
❑ MH
❑ Demo
ew
Add/Alter
❑ Replace
❑ Move
Other
14
Describe Work
10
Applicant Name
Street Address
11
Zip
City
State
1
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
i nis is not a Permit
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
Release
Rel a w/cond 1 Hold 2
Environmental Health
W. 1101 College
Room 200
❑ Commercial;esidential
❑ New Construction; �Idg alteration/addition
❑ Additional structure;
APPLICATION #
Conditions/ Comments:
❑
Planning/Zoning:
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
A
N. 721 Jefferson
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
-
El CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions /Comments:
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson
❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/ Comments:
Utilities:
N. 811 Jefferson
Conditions/ Comments:
Other:
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
c
1.
Z
E
O
2.
C
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
i
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