1986, 07-28 Permit App: 00012379 Pool(THIS IS NOTA 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)
Project Number if2 31
Owner's Name LAST• T
- _'
__
Project Address (Street Name & Number) Zip
f //�/ n�
!I e2 0 / gg,CA
Applicant
j
Address
City
State
Zi
Pho
Business Phone
( )
Contractor/Agent
Add
ess
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( 1
Lender
Add ess
City
State
Zip
Phone
( )
Describe Work y..,; - Res. / Comm.
.)/14,X.J.g._ Poop L ✓ 1
Subdivision/Plat Name/Sht
P t Number
1SS10kl Ig /de S
Assessor Parcel Number
661/1 — O /S`a►
Lot
I I
Block
Plat Number
Pertinent File Numbers
Zone �� ,
Aa
Comp. Plan
Census Tract
Number of Dwelling Units
1
Number of Buildings
I
Lot Size (Sq. Ft./Acre)
51 Q(o 8
Depth
2CC/
Frontage
ie)B
FrontSetback -
Left Setback
Right Setback
Rear Setback
R/W Width
Additional information
BUILDING INFORMATION I
Square Footage
r
-' •
°-. w.
Number of Bedrooms
Dale
-1-26-
Group
Type
DEPARTMENTAL REVIEW
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
Date
ll
Approve',;
Hold
Environmental Health Application #
11
,Approval
,I,
d
W. 1101 College
Room 200
, Ai
Planning/Zoning
N. 721 Jefferson
Engineers
N.811 Jefferson
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'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
Date
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