1984, 11-15 Permit App: 00003352 Repair Fire Damage . ..4100,.._.
BUILDING PERMIT APPLICATION WORKSHEET • ,N
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) (first) a (m) I Department Use Only
t" t 1 / 1* \ >> / 7/4=-6, r s. Comm
2 Project jot1/
Address(not Mailing Address)ar Road' Name Space Zip
/2 /G' ? of 9 O 7/ j i t.<'y t
3 City/Community State / Subdivision/Plat Name
(/e ,-n Q A/' Lv % V v; 4 r PO
4 Aresor Pa I No. / LotBlock
l jl I� 4t I * * * DEPARTMENT USE ONLY * * *
5 Sic Code) "� Zone Act.# Zone Project No.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Back-Front I(L)S-1 (R)S-2 l Rear Census Tract 1 Module No. Initials
*
* 16 Architect Firm Name I Street Address
Zip City State fl Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
v' L L CP / .4 k r/i i, r s3 U /� ' l C? ( e.,. ',-.4 JLC
ZipCityState Phone
/I3—
Contact Person License No. Phone if different than above
f(' u'J? N 19 'F..(1A0 ZVc(. 21C, 13z1 ( )
8 Owner/Agent(if different than#1 above) 7 24764 Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) SEPA Exempt(YIN) Date
15 Type Work ❑ Bldg ❑ MH C New ❑ Replace ❑ Other
Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
F, ✓ !✓194 , /-
10 Applicant Name Y Street Address
11 Zip City State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
Ver 4)fr o - 1,010 00 °= 0-0-6ar rvAcfto