1984, 05-15 Permit App: 00000216 Fire Damage Repair, Addition*
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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)
Departmen Only
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2 Project Address (not Mailing Address) ar Road Name Space Zip
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3 City/Community
State
Subdivision/Plat Name
4 Assessor Parcel No.
7 s 7 0� (, /
7
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No. j
. 6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
N 7 Set Back -Front 1
(L)S-1 i
(R)S-2 Rear
Census Tract
Module No.
Initials ---)-
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0
16 Architect Firm Name
Street Address
Zip
, City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street
Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check
k((Y/N)
Other (Y/N) JSEPAExempt(Y/N)
Date
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15 Type Work
0
Bldg
Fire
❑ MH
0 Demo
0 New
0 Add/Alter
IBe-e-Replace
0 Move
0 Other
14 Describe Work
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10 Applicant Name
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Street'Address
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11 Zip
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City
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State
rcJet.
Phone _
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Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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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;Residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION #
Conditions/Comments
Planning/Zoning: ❑ Commercial;
N. 721 Jefferson ❑ Setbacks;
Conditions/Comments•
❑ Cert. of Exemption;
❑ lot w/d; ❑ lot size;
❑ Frontage;
❑ use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments.
O Flood Plain;
O fence;
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
- Project Project Representative
a Agencies Performing Special Inspection:
c
o
o
m is
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rn o
m c
LL
Telephone
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
Conditions/Comments
Planning/Zoning: ❑ Commercial;
N. 721 Jefferson ❑ Setbacks;
Conditions/Comments•
❑ Cert. of Exemption;
❑ lot w/d; ❑ lot size;
❑ Frontage;
❑ use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments.
O Flood Plain;
O fence;
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
- Project Project Representative
a Agencies Performing Special Inspection:
c
o
o
m is
�`- E
rn o
m c
LL
Telephone
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold