1984, 11-26 Permit App: 00003492 Garage„
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
• rr
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name (Ian) (il t) . (m)
Department then ly
DO ~ (K /
Res. comm/,d
2 Project Address (cit Mailing Address) cr Road Name Space Zip
S 76Q Ma.t,t,. {L."-. 972' G
3 City/Community
State
lef--,71,.
Subdivision/Plat Name r
Mcg 0v -e S -aOen
4 Assessor Parcel No.
r 2,a 5 Lit --/32,--i
Lot
Bleck
* . + DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 0
Zone
Project No.
6 Dwell fl
l
No. of Buildings.
1
Sq. Ft./Acre
Depthr
n
Frontage
Isar
7 Set Back -Front
(L)S7
(R)S-2
Census nsua Tract
Module Noo
i i C
z
16 Architect Firm Name Street Address
13 sh0F
Zip
City
State
Phone
( 1
Contact Person
Phone If different than above
Contractor Firm Name
/trig F.< -1--11a (3,A3v4 c./e)'✓
Street Address
%3OiS /'"Ut ISc5(,_
Zip it
ci°i z
City
S�t(c,..-
State
wily
Phone
1 ) 53t./., la `c S
I ntat Person
'o.k, MLQ0. IJ
LI No
` 1 PtFec�--C_ i7C,35
Phone If different than above
( )
8 Owner/Agent (If different than 01 above) .•
Business Address
9 Zip
City
State
Phone
1 1
12 Review Required
Plan Check (Y/N) -
Other (YIN) I SEPA Exempt (Y/N)
Date
15 Type Work IC Bldg
0 Fire
❑ MH
❑ Demo
new
0 Add/Alter
Replace
0 Move
❑ Other
14 Describe Work
10 Ap nt Name
Street Address
ThlC
11 Zip
`7 ? 2 � ->—
Cit
5/j () !no —,_
State
L"— i--)—
Phone
( ) 5 3 1— ,o 9 3
Lender
Street Address
Zip
City
State
Phone
1 1
Contact Person
Phone d different than above
1 1
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
w
DEPARTMENT APPROVALS
This is nota Permit •
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health 0 Com rcial; B' Residential
W. 1101 College 0 Construction; 0 Bldg alteration /addition
Room 200 Additional structure;
Conditions/Comments.cirref_
APPLICATION #
Release
Release
w/cond 1
Hold 2
Pa
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone.
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments-
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments'
111
Utilities:
N. 811 Jefferson
Conditions/Comments-
0
Other:
0
Plan Exam
Fire Prev.
Condltlons/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
Condltlons/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
1130
30
57
NY