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1985, 05-31 Permit App: 00005725 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) 9 �c?{ Ci✓fit cc�i Department Use Only F33. Comm 't Address (not Mailing Address) Cr Road_Name Space Zip 2 J70ye c� )lit.e. Y7,?e, 3/Community //.•.--- Ole( State jorz,/ Subdivision/Plat Name �J �-C-ie--i ta-<4.--!J `4=- 1 Assessor Parcel No. . r / 5- J gevg Lot , Block I * * * DEPARTMENT USE ONLY * * * 5 Sic Zone Act. # Zone9E12.,Project No. 61 25 II # t -x r ;, uE�- ( No. of Buildings / Sq. Ft -/Acre .. n Depth ) (3S Frontage r CPg 1 Initials . 0 1\1 ►fy) . z._ Osnsus Tract Module No. 7 Set Beck -Front (L)S-1 k. / I /e' ' (R)S-2 /7 ' Rear ,/j? ` 16 Architect Firm Name Street Address Zip City State Phone ( ) Contact Person Phone If different than above ( ) Contractor Firm Nare 'V�C�r. k.LYC i -c—, ` r"�e,...' Street ddre ss /-�nts�/y( tL.yL�" 6.Q.C,�i' s� �a o City tState \ i ,f- Phone (60y ) 9,2Y--57,964, Cont erson/ Mc f iC.. ' ..y1 License No. fr--2 4• ✓ M.� (,z. Z. 7,6 Phone If different than above ( ) '' ARJ %� Y 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) LSEPA Exempt (Y/N) Date 15 Type Work E Bldg 0 Fire ❑ MH 0 Demo 71' New 0 Add/Alter ❑ Replace 0 Move ❑ Other 14 Describe Woyk i-\."jf✓,A,;•. �/ Ti A/i7c.e.e /Fac.L..,i_2 c-c'-e�J 10 Applicant NameCa/ '•-••••,77'-- l�X'.-e-Cz Cd—l(...xJt(,n ✓ '< a / Street Address C - %C) //2/' /ca the J 11 Zip c? Vie; 6 i City .4,:c i State fitizt— Phone ( 6 C 9 ) p2:f-vJ60 Lender Street Address Zip City State Phone ( ) Contact Person Phone if different than above ( ) Additional Information q� }Mr' V -r ,N i V Ai r, 7)(, t.= C E f i/ E E .� 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.) El Environmental Health W. 1101 College Room 200 Conditions/Comments ❑ Commercial; O New Construction; ❑ Additional structure; O Residential ❑ Bldg alteration/addition APPLICATION # Release Release wlcond 1 Hold 2 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; O CU, variance, zone change; shoreline; ❑ fence; O Other Conditions/Comments• Engineers: 0 Commercial; N. 811 Jefferson 0 drainage ❑ road improvements ❑ Residential; Q' new access/approach; ❑ Flood Plain O fence; evrio Conditions/Comments. 1►)�4 7D i-7 3l Utilities: N. 811 Jefferson Conditions/Comments Other: 7 5 a 0 Plan Exam Fire Prev. Conditions/Comments• Project 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 Lof aZ-o _IC af" �a.,, 771i ral A ci4i i/3 No R-4-14 as aye .3,1?.ee. C74 k 1° ) AV' x'11A 3: a6. /7 6f SZ 3701 South Lo Rd tbL