1984, 07-09 Permit App: 00001185 Residence 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)
(last) ' `` (first) (m) Department Use Only
1 11 c etslA .JCS S tom! I Res. \,/ Comm
2 Project Address(not Mailing Address)a'Road Name Space Zip
S. 2 2,5- . K.CP1,'‘.DCaczTL..t )
3 City/Community State Subdivision/Plat Name
V.0 K-6 CJ YC?i.0 i\3 k—C C
4 Assessor Parcel No. Lot I Block
2i�j,j , "' `rstZ * * DEPARTMENT USE ONLY * * ,t
i 5 Sic Code 'Zone Act.# Zone Project No. `�
-2 1-&4- .A . u
6 Dwell ff No.of Buildings Sq.Ft./Acre Depth 9.4.I Frontage'
t t r x /30
7 Set Back-Front (L)S-1 (R)S-2 f Rear Census Tract Module No. iAs
- v
*
* 16 Architect Firm Name I Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
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Zip City I State Phone
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Contact Person License No. II S"^/. Phone If different than above
c Ai1 Gt4" IJ i.2ctct ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Otheer/(YIN) LSEPA Exempt(Y/N) Date
-%S lei
15 Type Work li3lidg ❑ MH New ❑ Replace ❑ Other
0 Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
`CIS i g--) /QC-- u-1 a A -tx0
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 Information
LA rB `4-
. .,ter
DEPAhiTMENT APPROVALS • -
This is not a Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Track
❑ arly Start Release
_ [Release w/cond 1 Hold 2
Environmental Health Elmmercial; esidential i';LM
W.1101 College New Construction; CI Bldg alteration/addition l .('4.�
Room 200 ❑ Additional structure; J°'�!l
APPLICATION# '7` - G,�
Conditions/Comments: ad -Q 'jf l i -7 JAI '. Tv
-Ad
V
0 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; R dential; ❑ Flood Plain; ��-a9�B
. N.811 Jefferson ❑ drainage new access/approach; ❑ fence;
c-��
❑ road improvements
Conditions/Comments:
❑ Utilities: 1
N.811 Jefferson
Conditions/Comments:
CI
Other:
0 Plan Exam
Fire Prey.
Conditions/Comments:
a
u,
c
7111
5� Project Representative Telephone
ca Agencies Performing Special Inspection:
Y O
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rn 2.
(6 C
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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