1985, 04-05 Permit App: 00004797 Remodele
4
BUILDING 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)
Owner's Name (last) (first) (m)
I -••- /S!� r OISLei Don 2/d DalhPrf
Department Use Only
ice.
Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
.S, /97/ N6 r» e- r Kd . 79A/6
3 City/Community u
spQO/1o0a-
State
w4-
Su Ivlsion/Plat
VIc
Name
DL
4 Assessor4aroel
z.1Sj
No.
(_(349
Lot
Block
I
t t ♦ DEPARTMENT USE ONLY * *
5 Sic Cade
Zone Act. 4
Zone Project No.
ilt-l r .
6 Paella
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Beek -Front
(L 5-1
(R)S-2 I Rear
Census Tract I Module No.
Initials
16 Architect Firm Name I Street Address
Zip
Clty
State
Phone
Contact Person
Phone If different than above
Contractor Firm Name
Street Address
Zip
City
I State
Phone
( )
Contact Person
License No
Phone if different than above
' 1 )
8 Owner/Agent (If different than 41 above)
Business Address
9 Zip
City
State •
Phone ,
( ) R22 —06 7
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SERA Exempt (YIN)
Date
15 Type Work ' Bldg
❑Fiir�e
0 MN
0 New
❑ Add/Alter
❑ Replace
0 Move
NtOther
14 Describe Work - $ACmT f�/t�•DOE U (\1(0
)❑�D�e/moo c r
10 Applicant Name
Street Address
11 Zip
Clty
State
Phone
1 1
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
( 1
Additional Information
Val) °-� UwM7,oY3
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.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
.
Hole
APPLICATION #
Conditions/Comments•
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;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments-
0
Utilities:
N.811 Jefferson
Conditions/Comments
0
Other:
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