1984, 07-26 Permit App: 00001407 Additionw .trwo
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRtT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
INease return this original and your building plans to the Department of Building and Safety)
1 Owner's Marne ), (last) (first) (m)
/92 a1 A, tf(/,?g ,�.4"/i(Jy' / 0 IDeportment
Comm
2 Project Addrrfs (rot NtatNnp Address) or Road Name / Space Zip
5 - i3oS-11..64.n,pc,eK 5.503 c03 7
3 City/Community
(//_ A2,44/41 L'
State
fi�,ry .,
Subdivision/Plat Name
,'V c k -t Fore_,J A c rzTFz tAC -TS
4 Assessor Parcel No.
'2.4S // S.,_
Lot
--Th
Block
CJ �?
* * # DEPARTMENT USE ONLY * * *
5 Sic CodeZone.
tt
Zone
746k.
Project No. 4f 0 ?
/
6 Dws&I1
No. of Buildings
Sq. Ft./Acre
Depth
jZ
Frontage}
` o
Back-Front
7 Set Ba
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
s
Initials
16 Architect Firm Nance
Street Address
Zip
City
State
Phone
( )
Contact
Phone If different than above
( )
Contractor f°hm Name
Street Address
Zip
City
State
Phone
( )
Contact
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
Flan Check (Y/N)
Other (Y/N) JSEPAExempt(Y/N)
Date
15 Type Work B'-'BIdg
0 Fire
❑ MH
0 Demo
0 New
Q' Add/Alter
0 Replace
0 Move
0 Other
14 Describe Workf
'`iX,i Odd/ f/0/i fo tes/C/C/7. C./ j f
10 Applicant Name
i)4,vriV a 4706/7 ems
Street Address
S. /305 Sf-/,izn�d£r�l
11 Zip
9?0.2 7
Ci,y �
(/tti:4,04iL
State
a UV.
Phone
( ) 92L -S G L
lender 1Street
Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Additional Information'
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; ' esidential
❑ New Construction; Bldg alteration/addition
❑ Additional structure;
APPLICATION #
Release
Release
w/cond 1 Hold 2
0.71
!
.G.MI
Conditions/Comments.
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments.
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial;
O drainage
O road improvements
O Residential;
O new access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/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
7-