1984, 10-18 Permit App: 00002926 ResidenceBUILDING PERMIT APPLICATION WORKSHEET �C
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) I (first) (m)
�-
I U' 4-6- �i ( N
Department Use Only
Res. Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
S 3(z as- L. i0 ✓ e A-- bre
3 City/Community
)
`
State
r .i
Subdivision/Plat Name
i'60 ri
4 Assessor Parcel No. ) %
)5 $ / J Cool LL
/
Lot
Block
Li
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. k
Zone
srF
Project No. .--, til 6.-.47-
6 Dwell kNo.
/
of Buildings
/
Sq. Ft./Acre
Depth
/ZS
Frontage
9C,
7 Set Bads-F�t
I (L S-1
(R)S-2
1 Rear
Census Tract
I Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
(A)U-c-Z) Co--- ;.1
Street Address
/ of 5 , q //,4-ic ; le-- -
Zip
)5005e_isC.-e.T
City
State
to t.
Phone
(Sc',) 40-8 i I
Contact Person
-, AcnneS E ( iL3e---( t S
License No.
ije _ t_c- c_ Zoc; 1)
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 (Y/N)
Date
15 Type Work Bldg
❑ Fire
E MH
❑ Demo
IL/New
E Add/Alter
❑ Replace
E Move
❑ Other
14 Describe Work
r e =- i cle vc�, CJ°te2 r`; e, (/ //ae he �i
10 Applicant Name /
t4—L0 Cent- ;
Street Address
/v / `t 5 i y /f 2 i
11 Zip
9GDOs
City
La L._,./..4.4
.._J..4
State
LA) l,/
Phone
(6.741 ) 7-5(/t'/
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
52-5 l+idF E x2 4 I -De k
1 L s -F 5-ZF 04/C 11...1 il
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
Environmental Health
W. 1101 College
Room 200
Conditions/Comments.
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
It :t
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments
❑ Flood Plain; 4 ,
❑ fence;
El
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
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
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