1984, 06-28 Permit App: 00000346 ResidenceBUILDING 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) (first) (m)
r [apartment L)se Only
Go CD cIQe-.'/ CoLIS J Kv :1-7°4 i GYmi p4A/ ¥
f �. ✓/ Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
S•3Co15 1.04:1017)e-14 FF "2(3 .
3 City/Community
S? c)<A1 Ai,E.:
State
W r4
Subdivision/Plat Name
PONpzgar/5k y ADD, r,-0 kJ
4 Assessor Parcel No.
•5'1- - 2-..0 ,,f.
Lot
Lor y
I Block
I 3
l
* * * DEPARTMENT USE ONLY * ,t ,t
5 Sic Code
Zone Act. #
Zone
Project No.
1
6 Dwell #
1
No. of Buildings
1
Sq. Ft./Acre
Depth
t nom'
Frontage
l oS#
7 Set Back -Front•
(L S-1 •
(R) ; Al Rear
Census Tract
Module No.
Initials
* 16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
GoCDC GXe-.47- (-0itis i itocTivA) Co .
Street Address
f. 07oy GoLDex RD.
Zip
c19aog
CityState
S poKkl4vE
( kJ
Phone
(jO7) v46 - 8i i
Contact Person
License No.
Phone If different than above
r.l orgph T' %Roy _
aD3-CI 4,oLPEcc
/7.54 S
_ ( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N)
4 c
Other (Y/N) SEPA Exempt
(Es I `(Es
(Y/N)
Date
15 Type Work Cr"-Bidg
E Fire
, MH
, Demo
X New
Add/Alter
Replace
1I Move
7 Other
14 Describe Work
Si'- r,LF F#4M, z -Y Re-.; ,'Dt Ait:„E. wiAt/TpchE.A
Gp iZ,q&,_
10 Applicant Name
Street
Address
11 Zip
City
State
Phone
Lender
CoL o,,I $/'f? SERV%GAS
II%DKT6.Cp .
Street
Al
Address "
• J et, ,a9R6-0.,v /c RD .
Zip
9'4("6
City
S po KA/vr-
State Phone
w,144 ( ) 90.) - /a o 0
Contact Person Phone if different than above
DE 196) Ja htiu-o.JJ ( )
Additions! Information
+404
DEPARTMENT APPROVALS
❑
■
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
I r I1, I S I lu t o rat 1111 t
(Indicated approvals required In either "release° or "release with conditions'
to issuance.)
space prior permit
-
Release
w 1
Hold 2
{--(J//
Environmental Health ❑�Commerclal; Li/ResidentialRelease
W. 1101 College ce New Construction;_ 0 Bldg alteration/addition
-
Room 200 0 Additionalstru,crtura; �f'!J'
APPLICATION#e' 6?y 9
s � nflC (x`17 '�iy�- /L@ct.�
Conditions/Comments'
.
1/O Y
(/
❑
Planning/Zoning: 0, Commercial; 0 Cert. of Exemption; 0 Frontage;
0 lot w/d; 0 lot slze; 0 use/zone.
N.721 Jefferson 0 Setbacks;
❑ CU, var:ance, zone change; shoreline; 0 fence;
❑ Other ".
Conditions/Comments'
Engineers: 0 Commercial; sldential;❑ Flood Plain;
_o;
�Y�
N. 811 Jefferson 0 drainage ,d new access/approach; 0 fence;
❑ road improvements
Conditions/Comments' '%
•
Utilities:
N. 811 Jefferson
Conditions/Comments'
•
-.'
Other:
0 4C
•
Plan Exam
, r�/
S iy��"W�-
Flre Prev.
Conditlons /Comments -
1 Information` ❑I
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
1 .•
,Goh oentscesr Co usra vc1 ? b.0 Go
•
Lor 4 $LOCK 3 rpNad/tar 4/3r /tab .
t14
/00
ele
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MN IL I&V, /Oyu
7'
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as
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