1985, 06-11 Permit App: 00005869 Siding*
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) (first (m)
Department Use Only
/ n KeJO' 'l WRas.
C�
V Comm
2 Project Address (not MailingAddress) or Road Name Ibpace Zip
/�
C. 126, / / r 1iiiicl'e 9¢( 2
3 City/ munity
Ca
State
l/ `� /
Subdivision/Plat Name
4 Assesso ParceliNo. /
0-7-4 Z— MO i O
.
Lot
Block
r
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
1 .c, `SCA
Project No. `
6 Dwell #
No. of Buildings
1
Sq. Ft./Acre
1 j v
Depth
Frontage
7 Set Bads -Front
(L)S-1
(R)S 2
1 Rear
Census Tract
Module No.
trr
Initials
C
16 Architect Firm Name
Street Address
1
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name/
- t t/ -Cf. e,,,-,
Street Address
n. 3/06, nrz.. e4'
Zip
q9 /2
Cfty
/C C
State
>4
Phone
(sV) q..21-y6V.C.
Cont Person
License No.
Phone If different than above
6 ner/Agent (if ifferent than N1 above)
Business Address
9 Zip
City
State
Phone
( 1
12 Review Required
Plan Check (Y/N)
Other (Y/N)
FSEPAExempt (Y/N)
Date
15 Type Work D Bldg
0 Fire
❑ MH
0 Demo
L
❑ New
0 Add/Alter
0 Replace
0 Move
' -
Other
�f�
14 Describe Work
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10 Applicant Name
Street Address
11 Zip
City
State
Phone
( 1
Lender
Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone if different than above
( )
Additional Information
en ` L _OVI t c v V
liaito/q/A4V6
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
Conditions/Comments
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Release
Release
w/cond 1
Hold 2
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments•
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions /Comments•
❑ Flood Plain; I
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/ Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments-
Project
onditions/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