1985, 07-03 Permit App: 00006260 ResidenceBUILDING 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) t Oniy
Ll
R.Re M ktae ( 1 (-7 IDepartmen�' ✓ Comm
2 Project Address (not Mailing Address) n Road Name� Space Zip
r-• 109 12 1mrA%.tAte ll 1Q`?,KJ'F- 992-o6
3 City/Community
55po ku o 2
State
(A) 0_51)
Subdivision/Plat Name I
jrc trio n) ari1
4 Assessor Parcel No.
\bs4z-\4O-7
Lot
7
Bieck
3
i i DEPARTMENT USE ONLY * * * r
5 Sic Code
Zone Act. N
Zone
Project No /' ,�� 0
6 Dwell p
k
No. of Buildings
Sq. Ft./Acre
Depth .// 1
1110
Frontage
Ci
7 Set Back -Front (LS -1
4S' -24--24-
(R)S-2 Rear
I `
census Tract
Module No.
5
Initials
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
( )
Contact Person
License No.
Phone if different than above
8 Owner/Agent (if different than 01 abo e) Bus' ess Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) ISEPA Exempt (VI N)
Date
15 Type Work 13' Bldg
0 Fire
0 MH
0 Demo
4e New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
IZCStCIE NC.E W(S4\21\C6
10 Applicant Name
M;cInav
1
o_2
Street Address
103o.� E Das tM t
11 Zip City
�ty
(A 50 o {C a n Q.
State
Was k
Phone
(5 09) 9) 9 2 L,I 'd' 41A q
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
Additional Information
mE =I(621 P E-11
1)6 it ►o6z0 IUI JUL. 31935 1111
6/ -X038 at1.\\\F EU
f
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
6 -
DEPARTMENT APPROVALS
This is not a 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;
?Tr- ?.676p
.3
APPL)SATION #
Conditions/Comments' '&t4/ - 776I- AA; -0> f"U nl`L
Release
Release
w/cond 1
Hold 2
:7.,
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; X Residential;
N.811 Jefferson 0 drainage new access/approach;
O road improvements
Conditions/Comments
I=N'A- - yi7
❑ Flood Plain
❑ fence;
0
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Condltions /Comments•
fit
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
a i 4'1
3
s
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