1986, 03-04 Permit App: 00009960 Residence(THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
37C
OflMLJCU HIltMO paw run uCrMl'1 i IVI eIN 1 HL uoC
Project Number q940
Owner'sName,�/ -,.l LAST FIRST MI
-
LU•/2 S SC "SOC- /Z/ •
Project Address (Street Name & Number) - Zip
03n A s -v Gn,v,nc CT QQ2«
Applicant
Address
City
State
Zip
Phone
Business Phone
I )
Contractor/Agent
W 4 S vt its -rocs f
Add
ass --
_ • P fso x. ./ stoic/ • \-`-
City
ecr Oyeirt2/Q
State
aliCV
Zip
^^,,
fr'#V
Phone
( )
Contact -
alCC S.'ytrrl
License Number (Required)
WhsOs-2
yr M6
Business Phone
( ) PA2-a7t'Z_.
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
I Zip
Phone
Describe Work
--S;atf r»»i • £ee-r itPoL/C.'e—
Res.
Comm.
Subdivision! Plat Name/Short Plat Number
--MA RACE Bleu/ Sr-0/nn fir / 249
4/
Assessor Parcel Number
2-15-4)4 - C1o09 PT /1/4)
Lot
/ 0
Block
/
PtpLNumber
C�
Pertinent File Numbers
Zone SR
Comp. Plan
Census Tract
Number of Dwelling Units
(
Number of Buildings
(
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback
Sc r
Left Setback
30
Right Setback
/7 '
Rear Setback
71—
R/W Width
Additional Information
I BUILDING INFORMATION
Square Footage
C73 = A -e
1/62=CAe
Number of Bedrooms
Building Technician
Cyd
Date
o -0V-86
CALLceo
Group
R— 3
Type
vn1
Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Application N
g 6- 0/22
Approved
Cond.
Approval
Hold
Planning/Zoning
0 N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
-.0-27d61‘0
Utilities
❑ N. 811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/CrItical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application Is true and correct.
Signature ��--/�yl•�'�^�
Date
YVir
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