1984, 07-24 Permit App: 00001346 MHosne ""5°1
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)
1 Owner's Name (last)kt. (prat) Iml
�Ame
Dspartnient Use Only
5
/0 /fly / fe�—
Comm
2IDOC/S0
Project Address (not Mailing Addrese�))J/cr Road Name Space Zip
X19002 /%1,ae/tile, //S Oz•rim F4/s /.ca_ 990 7 %9027
3 City/Community C.,-)/
//
£9&s �/'ct1,Rc✓S
State
G)0—
Subdivision/Plat Name
' 4 Assessor Parcel No.
-• 05 V2 =' 6.411
-
Lot
11
r
Block
3 ; ,. -* DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act.N
ZoneKM
Project No.
8 Dwell 0
No. of Buildings
Sq.
Ft./Acre
Depth 1
t I 7
Frontage t
76
7 Set Beck -Fran( (L)S-1
-- —
(R)S-2 I
Co ' 25
Census
Tract
Module No.
Initials
JUN Y1') .
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
1 )
Contractor Firm Name
Street Address
Zip
City
State
Phone
1 1
Contact Person
License No.
Phone if different than above
8 Owner/Agent (if different than 01 above)
Bus! ess Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
ISEPA Exempt (V/N)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
' Replace
0 Move
0 Other
14 Describe Work
e.e Die e e //l o3 i /e AO) c ill IL
. ,n e (A) m n,6 /e ,An> ->tic 25 )(CPO'
10 Applicant Name
lbd01cS-O A JA+k()Nst✓
Street Address ////
�/9e5 7 /12.9,e e/%
11 Zip '
990 Z'7
City
.0A5 O A,c%
State
4_20._
Phone
(5V ) j12- a' - GPY 9 S --
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
( 1
Additional Information
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.)
LrJ
Envl ron mental' Health
W. 1101 College
.Room 200
Conditions/Comments'
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION 0
y
❑
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;
O Other
Conditions/Comments
El
Engineers: 0 Commercial; ❑ Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions / Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
Plan Exam
Fire Prev.
Conditions/Com ments•
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
Release
Release
w/cond 1
Hold 2
Vidi
❑
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;
O Other
Conditions/Comments
El
Engineers: 0 Commercial; ❑ Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions / Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
Plan Exam
Fire Prev.
Conditions/Com ments•
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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