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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