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1984, 12-19 Permit App: 00003774 Remodelr, oO 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) �J (first) (m) �.42tniti /4.6Ai/2) I7epartrtlent Use Only Ft. Comm 2 Project Address (not Mailing Address) v Road Name Space Zip E.IV/9 ara- 3 City/Community,' d n.kd�he _ State 614 — Subdivision/Plat Name// /'�/ /.Sts t7&rit vi 5 5- /4 i4f4� /dA% 4 A r Parcel No. 076—'-/9 —0 so 9'• Lot G / Block p 3 r ♦ * DEPARTMENT USE ONLY * * 5 Sic Gide Zone Act. 0 Zone A co`V 1 Protect No 3-77 j (�I 6 Dwells No. of Buildings Sq. Ft./Acre Depth Frontage 7 Set Bads -Front I(L)S1 (R)S-2 (Rear Census Tract Module No. Initials 16 Architect Firm Name I Street Address Zip City State Phone ( ) Contact Person Phone If different than above ( Contractor Firm Name VP -4'r / /rrtu��rt/l� Street Address ' b 2— Sex 22gP- Z 99202 Gty S/y�s��s State 64-4 , Phone 92g-2707 Contact Person / Salter -_ License No. laciRGc/c4/C 7) Phone If different than above ( ) 8 Owner/Agent (If different than 01 above) Business Address 9 Zip City State Phone 12 Review Required Plan Check (V/N) Oth r(V/N) ISEPA Exempt (Y/N) Date 15 Type Work Bldg 0 Fire 0 MH ❑ Demo y❑New r�( Add/Alter 0 Replace 0 Move 0 Other 14 Describe Work i l'f t n) (tbMo P EAAA fJ co — CPmPcoE ©..,Dn rd n'1 10 Applicant Name Street Address 11 Zip City State Phone ( 1 Lender Street Address Zip City State Phone I ) Contact Person Phone if different than above Additional Information - 3 000 00 = i DEPARTMENT APPROVALS 1 Indicate above or attach conditions relative to final as built approval 2 indicate above or attach reasons for hold Inisisnot aPermit Application Type (Standard unless otherwise indicated) (Indicated approvals required in either "release" or "release with conditions" space prior to permit issuance.) • Fast Track Early Start Release Release w/cond 1 Hold 2 Environmental Health ❑ Commercial; ❑ Residential W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition Room 200 ❑ Additional structure; APPLICATION # Conditions/Comments: 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; ❑ Flood Plain; N. 811 Jefferson ❑ drainage Cl new access/approach; 0 fence; ❑ road improvements Conditions/Comments- Utilities: N. 811 Jefferson Conditions/Comments: • Other: • Plan Exam Fire Prey. Conditions/Comments• Project Representative Telephone c O Agencies Performing Special Inspection: 1 03 E O 2 c 3 1 Indicate above or attach conditions relative to final as built approval 2 indicate above or attach reasons for hold