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
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aye
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3701 South Lo Rd tbL