1984, 12-18 Permit App: 00003775 ResidenceBUILDING PERMIT APPLICATION WORKSHEET •
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please ;turn this original and your building plans to the Department of Building and Safety) [�se2.
st)[ spa ment be Only
1 Owner's Name �+ (m)
m)
I
Comm
sZip
2 Prot'' ddress (not Mailing Address) a Na Space---yyyjrgS7G.,-r /Air p
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3 City/Community
5 /CG'-, P
State IIubdivlsion/Plat Name �
Gc-' /r -etas
t r3 ivy C ►.*z
4 AsawSor Parcel No.
1(45 4 l4 —01Q7
Lot
7
/7
Block
� * * * DEPARTMENT USE ONLY * * *
5 Sic Cade
Zane Arlt. N
H—
Zone '71 gs Project No. 3 7.6
t.th
6 Dwell II
1
No. of Buildings
4 1
Sq. Ft./Acre
Depth
30o
Frontage
g '
7 Set Back -Front I I (L 8_1 I
II 8
(R)S-2 1
Rear
Census Tract
Module No
Initials
�16
Architect Firm Name Street Address
Zip
Gty
Stale
Phone
( )
Contact Person
Phone If different than above
( )
Contractoryn/�`rtn Name /r�� /�� /Q
/(_.
Street Address
7 7 / / ( ley ���
FPhon
Z g (V 159
Gty a
State
(CO q) q c
tact Person
CC/- �� --e.., 5
License�f p.,
4J 5%Y2fl19710
Phone If different than above
' l f
8 Owner/Agent (if different than #1 above) Busl Address
j2-2___ o9, e5 S k ei
9 Zip
W9031-
City
Vevado7
State
Phone
( ) 927 8/38
12 Review Required
Plan Check (Y/N)
Other (VIN) I SERA Exempt (YIN)
Date
15 Type Work Bldg
0 Fire
0 MH
0 Demo
/"- New
0 Add/Alter
0 Replace
0 Move
0 Other
14
14 Describe Work ga ( ilo \i (41 �6F-
10 Applicant Name
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City,
State
Phone
( )
Contact Person
Phone If different than above
( )
Additional Informatmn E C e I v C
rnF = l42 i
1)6 . 11-21A D DEc1S1984
(,1.: 483/ EC
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.)
0
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
O Additional structure;
APPLICATION # // A 1 / �1
Conditions/Comments a"U7ti-Y Oo..,.�1.,.-7 Taf ge-Lc.
o Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
/2
0
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; 0 Residential;
N.811 Jefferson 0 drainage E 1 w access/approach;
O road improvements
Conditions/ Comments•
❑ Flood Plain;.
❑ fence;
Utilities:
N.811 Jefferson
Conditions/Comments•
Other:
Plan E
Fire P
xam
rev.
/.'i�% 5"//
/2
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
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