1984, 05-10 Permit App: 00000150 ResidenceBUILDING 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) (m) DapartmenOnly
'!f //re e� �]ii, �� / 143s. Comm
I
2 Project Address (noting Addresa) a Road Name Space Zip
-41-0151- L a g e. 'bict I) k', v e.
_
3 City/Community
State
Subdivision !Plat
WI, i,
Name
0 c rvi 3.0,10
4 Assessor Parcel No. ID re,. G r
5.4 S4 I — 406 ` �T /
Lot
Block
7
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Protect No. 50
6 DwelI #
S-;11 e ,/
No. of Buildings
J
Sq. Ft./Acre
/a ps o
Depth
/,FS
Frontage
/0 0
7 Set -Fro
-70'
Intt(S-1g
(R)S 2
/'2 `
Rear
50
Gbnsus Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Pell A' C ah .iJ., c-
Street
1/4S--
Address
s---/ 0-1 11-1 (3 ill 64't., k /0/
Zip
9 9 0
City
Sia
State
Y�/ q S A
Phone
) s C 0
rileik
Contact Person ense No.
f'� r? €.ci P� FZ e cvf r
aa- '
Phone if different than above
(S,8) "3 6 0
8 Owner Ag nt (if different than #1 above
V`
Business
Address
S1 41.,A
9 Zip
City
State
Phone
( )
12 Review Required
Plan Chec (Y/N)
Other (Y/N)
SEPA
Exempt
(Y/N)
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
V New
❑ Add/Alter
D Replace
❑ Move
❑ Other
14 Describe Work
Z,6Sc COE'NC-C
10 Applicant Name
Street
Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
IiiAdditional Information
C(.Vv dAI V`-) t La_
tO
X24.44 A -2a,
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early 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
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/Comments
Planning/Zoning: ❑ Commercial;
N. 721 Jefferson ❑ Setbacks;
Conditions/Comments•
❑ Cert. of Exemption;
❑ lot w/d; ❑ lot size;
❑ Frontage;
❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions/Comments•
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
a
c
C ❑
_ld
N
coc
o
o •
to
I- E
o
o
m `c
LL
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
(11cs
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