1984, 06-19 Permit App: 00000727 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 (Iasi) (first) (m) Depertmenly
+
69/C AJ 6- CO /7 DR U 4 Con s / - fNc . Rss.
I
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
l 1 Q2-4 . f (/� '-4 tk F1 c./P
3 City/Community
o a vl e Cho u hi y
State
11-145 A .
Subdivision/Plat Name Z_L) p AD(.)
.-4)11. D Q'(. ±K . '17 SSI
4 senor Parcel No.
/h 3 -/3 3
j 4/!;
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone 5 � R-
Project No. 12/1
6 DwelI8
No. of Buildings
I
Sq. Ft./Acre
Depth
I3 I
Frontage
clo
7 Set Bade -Front
G(
(L S-1
14
(R)S-2
2z
Rear
Sol
Census Tract
Module No.
Initials
\I
(1( 4
16 Architect Firm Name
egf16- et, n)54orn Co ^51. Tic.
Street Address
11 61/6' w11,ieAoa5e_
Zip
”el°<7
City
®4)14aine
State
w .... irk
Phone
(sag) dif _ly..2a
Contact Person
e R A 1 G..
Phone if different than above
( ) - 4t -22 -IC)
Contractor Firm Name
eR.A!1:,.- co. G�aG eDr.ST� Inc.
Street Address
Zip raty
i
State
0 -tc-Iiii
Phone
( )
Contact Person
License No.
223--o t CRAi 1A239 CAN
Phone if different than above
( )
8 Owner/Agent (if different than 81 above)
5'iflme.
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN) I SEPA Exempt (Y/N)
Date
15 Type Work i5 Bldg
/Yew S F it. ❑ Fire
❑ MH
❑ Demo
Iti3 New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
10 Applicant Name
e le M4.- Co A a /Z6n
Street Address
11 Zip
City
State
Phone
( )
Lender •
Sect Ft Zs`t' Mot -6.A&E •
Street Address
N (01 RIVersib e '
Zip
cii5A0)
City
5-eoA2P1 e
State
f..sz--)Qs1x.
Phone
( ) `.6-4 :/3,73
Contact Person
S V. a lZ o v. l ly, INA a & .
Phone if different than above
( )
Additional Information
Ilio o zfr tJt 'o iz, e(%5/FX`
1
•
DEPARTMENT APPROVALS
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release I w/cond 1
Hold 2
Fr"Environmental
Health ❑ Commercial; 0 Residential `�o
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
ie l'v
�' �'�i
APPLICATION # g(---06 /
Conditions/Comments' (� % -iPtfL -44/1'1f-6A"(8-4"
t6-6-ca)
,.Y223
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments.
Fit
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
5 3a•g''
-
0 road improvements
Conditions/Comments*
Utilities:
N. 811 Jefferson
Conditions/Comments •
Other:
•
Plan Exam
E4)
Fire Prev.
y y
Conditions/Comments.
Information ❑l
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
0
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1.3 7,;441c:. .4I
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