1984, 10-31 Permit App: 00003048 ResidenceBUILDING PERMIT APPLICATION WORKSHEET `rte)
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 N �%as _ / f' st) (m) Department Uee Qnly
ty' 1��,�J �� // `� Fps. /
I
Comm
2 oject dress (not Mailing Address) cr Road a Space Zip
/ R C 4� //ee'firiC 1
3 City/Com unity �)
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tate
f
Al
Subdivisio /P --t Na •e '/ . /
�! . //� l� Ziff ✓ f 1,
4 Assessor Parcel`OZ
Lot
Block
f�J
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
ZoneProject
No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
1
(L)S-1 i
(R)S-2 ) I Rear
10 —
Census Tract
Module No.
Initials
.1 UM im
16 Architect Fi �� � wLs (7,76�( • /,U rStreet��Addr-�
a 1 ��
Zipy�27,-...........
City
State
Phone )
Contact Perso,<0'...., �" CG��C�!
Phone if different than above
( )
Contracto/Ali e 1 /
��/N C /
-
Street
Address
/4)C
/
Zip
City [State
Phone
( )
Contact Person
LIIccens¢M Q. i fA LS
,� �.1� -4 LL
Phone if different than above
( )
B Owner/Agent if)fiff ent t an ft above)
%� .�
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check (Y/N)
Other (Y/N) [SEPY/)
Dale
15 Type Work --13...BJdg
0
Fire
E MH
0 Demo
❑ New
0 Add/Alter
l
❑ lac
0 ove
❑ Other
14 Describe Work ?
iR
10 Applicant Narr n _
/(i//�,(I'`j
7 (2
(767/577//lJ/
//0
Stree Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Additional Information
tf 12-00A 2.13 iZ
1) % -- I IOO il 3 FIv
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.)
givd
Environmental Health
W. 1101 College
Room 200
Conditions /Comments
❑ ommercial;
New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
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 El drainage 8' new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments.
f'V4 -spy
Utilities:
N.811 Jefferson
Conditions/Comments-
Other:
Information
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
Release
Release
w/cond 1
Hold 2
S
•,)2z -‘1
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 El drainage 8' new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments.
f'V4 -spy
Utilities:
N.811 Jefferson
Conditions/Comments-
Other:
Information
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
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