1985, 04-22 Permit App: 00004827 ResidenceR
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BUILDING PERMIT APPLICATION WORKSHEET
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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''ss Mane (last) _—/ .r,_ (first) (m)
3— f 48-41:-; G p i- e) e mac`_
Depart lse Only
Fie. /
Comm
2 Prolect Address (not Mailing Address) or Road Name Space Zip
S. 31t4 UYCoQ/WFF W.
3 City/Community
jeluket ta.1/4___
State
CAJ It-
Subdivision/Plat Name
b4.4 5-11 I 4 4 d e sAI- .94f* aJJ.
4 Assessor Parcel No.
32C 9/ `!L$ i d
7 Ci
Lot
r
Block
+ .. DEPARTMENT USE ONLY * * *
5 Sic Code
Zona Act.1
Zone Sf„ / Protect No. 45 c�
I' hSgq..
L�
6 Dwell 0
t
No. of Buildings
I
Ft./Acre
Depth
(LJ6
Frontage
I
7 Set Bads -Front
30'
(L 5-1
Zs
(R)S-2 1
zS1NI
Rear
Census Tract
Madul No.
Initials
(*.1 m .
18 Architect Firm Name
Street Address
Zip
Qty
State
Phone
Contact Person
Phone If different than above
( 1
Contractor Firm NameStreet
Address
411.120 /v-j(a..-.A...-
3—'7?. it i-ef.�s .�he-
Zip9 F Za 4
QtySter k 4 «.t
Etat
Phone ) 91 Y— ci,s-i i2_
�y Pe son
(fa .- i MoaA -C
License No.
I H K aV IO2F2� .70 )e(
Phone If different than above
)
8 Owner/Agent (If different then 01 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (V/ N)
Other (YIN) I SEPA Exempt (V/N)
Date
15. Type Work $ Bldg
0 Fire
❑ MH
0 Demo
tK New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work 11) \IC C3J -612 S
10 Applicant Name
Street Address
11 Zip
City
State
Phone
Lend17LL M
Street tddress
1-1 -- /o . MA At n AV --
Zip
City
State
Phone
Contact Person
Phone If different than above
( )
Additional Information
trtF -7-)338 f U,Sc.OEGK = 3G e I' E
�EC
2F = o1Zo APR Opt 195D
us = 1st of I LAEr v
60(L z 502
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit Issuance.)
0
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
RS -Oa )3
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Conditions/Comments d- ' & " j Ate-. Li `I- t4
Release
Release
w/cond 1
Hold 2
vJ r•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N.721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments•
L
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements , _ 20.71
ConditionslComments• /" //�//T
0
Utilities:
N. 811 Jefferson
Conditions / Comments •
Other:
Plan Exam
Fire Prev.
Conditions /Comments:
Protect Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold
n
•
ry i•
• 4 ' A•ADDRESS:
General -
O Ownership Health
O Applicant Idcreased Lot Coverage?
t'Contractor Addition Bedrooms/
Fixtures?
O Architect Change of Use?
New Septic?
C. 391`1 wixiofff
PROJECT M:
Address -
icLegal Description
`Parcel Number
%Zoning
?Site Plan
Plannin
Unplatted Property?
Lot Depth: Width > 3:1?
(Less than 10 acres)
Lot Depth: Width > 4:1?
(10 acres plus)
Lot Size Less than Minimum?
Segregation of Platted
Property?
O Plat Map Setbacks Less than Required?
O Permit Description Frontage less than Required?
O Plans Not a Permitted Use in Zone?
O Completeness Rezone, Conditional Use,
Variance Involved or Required?
O Square Footage Commercial Use or Home
Occupation?
O Occupancy Group & Type More than One Residence?
O Departmental Releases Adjacent to a Required
and Conditions - Shoreline?
REVIEWED BY:.
En•ineerin
New Access/Approach?
•Private or Unmaintained
County -Road?
Se.a
Underground Tank Over
10,000 Gallons
Commercial Building Over
12,000 Square Feet?
Over 20 Dwelling Units?
Over 40 Parking Spaces?
Agricultural Building Over
20,000 Square Feet?
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical
Use Activity
Yes No N/A
DATE: 1/1/�)r
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