1985, 02-27 Permit App: 00004326 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 I.. ner's Name (last) (first) (m) Department Use Only
1.4 Ras. v./ Comm
-K. Cd h.5 /lr-1-ctio I
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2 Project Address (not Mailing Address) kr Road Name Space Zip
O ,3
t. o r P7 f 6, - -3-iT h -&-:-r te . S . 3SZA (-0 (1. - t -i PO -
3City/Community
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State
(ti2O(...
Subdivision/P at Name
./t11 I. 10 "4 � 3 P.1 A,>ei. rL'e)-c
0
4 AssParcel No.
3 C-.1 foo 2'
4 I -
Lot
i�
Block /
p
* + ,t DEPARTMENT USE ONLY
5 Sic Code
Zone Act. N
Zone �r
Project No.3
t
6 Dwell 0
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bade -Front
2 i
(L S-1
11
(R)S-2
Rear
7b i
Census Tract
Module No.
Initials
SUN m-
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
(? `ULAS rrKctl'ol.-,
Street Address
9-3.2 5-- l `Di^a51c..z
Zip
qq /,2
City �1
/7goKa,,,-t
State
t,/G.
Phone
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Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than 01 above) 1i I S ti:
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other (Y/N) I SEPA Exempt (Y/N)
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
'�' New
E AddlAlter
❑ Replace
❑ Move
❑ Other
14 Describe Work pP�'(����� -7 f �� A
t/ iPF4) �/ *^r f7 CfI—,f' 6Of`�6 i
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
OB z.-- 13
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Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions/Comments.
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
0 Bldg alteration/addition
APPLICATION #
Release
Release w/cond 1
Hold 2
Planning/Zoning:
N. 721 Jefferson
O Commercial; 0 Cert. of Exemption; 0 Frontage;
O Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; ❑ fence;
O Other
Conditions/Comments.
Engineers:
N. 811 Jefferson
I l/1
1 /
0 Commercial; 0 Residential; 0 Flood Plain;
O drainage 1 new access/approach; 0 fence; -00t i 1
O road improvements
Con.'t''ns/ • :is•.. I 4 "/'
i.��_�'% ' Li'l%
/
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
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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
• Y
"I EXCEL"
�r MARK OF EXCELLENCE
BRICK From r
Date:
Subject:
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SALES OFFICES:
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WINNIPEG (204) 943-906<
r..•..•.n _ nn•• Tu C • CCW O DIDC • AC1f) PRICK • COOLING.TOWER BLOC