1984, 08-03 Permit App: 00001575 Addition*
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 (last) d (first) (m)
6416h RI 4 i t ei NA; / (� A y
Department Use Only
Fes.
Comm
2 Project Address (not Mailing Address or Road Name /( Space Zip
E. 7/1? 4-/I7 ?9z/Z
3 City/Community
/ 1d7 / N t
State
Subdivision/ Plat Name c�
Z
(, t J p
Lot
4 Asad
2 1 I ^ 3 40 C/f
//1
n 7 ./1b
Block
2-
* . * DEPARTMENT USE ONLY it * *
5 Sic Code
Zone Act. #
Zone
Project No. j /
5 5
6 Dwell k
No. of Buildings
Sq. Ft./Acre
Dept (
12-7
Frontage
O'
7 Set Back -Front
�/�.
I (L)S-1
--
(R)S-2 Rear
_
Census Tract Module No.
I
Iniials
JuN M ,
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
Phone
1 1
Contact Person
License No.
Phone If different than above
( 1
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( 1
12 Review Required
Plan/�Check (YIN)
Other (YIN)
SEPA Exempt (Y/N)
Date
15 Type Work I/F+" Bldg
E Fire
7 MH
❑ Demo
1
11 New
/ Add/Alter
7 Replace
:7 Move
"1 Other
14 Describe Work
eic z I ..yju_s• A901 f!On{
10 Applicant Name
Street Address
11 Zip
921Z,
City
S;a /6P'iv6
State
/VA .
Phone
(Soy) yzz -/q7L
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
a
c
c
c
To
U
0
w
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LL
•
DEPARTMENT APPROVALS
■
fa
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
This Isnot a Permit 1-A.
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit Issuance.)
ReleaseR/
Release
w/cond 1
Hold 2
0 ResiBldg alteration
W. 1101 ontal Health 0 Commercial; Construction;
W. 1101 College 0 New Construction; ❑ Bldg alteraticnladditlon
Room 200 0 Additional structu9
APPLICATION 11 i
Conditions/ Comments'
0
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot wld; 0 lot size;- 0 use/zone•
❑ CU, variance, zone change; shoreline; ❑.. fence;
0 Other
Conditions/ Com ments•
•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
❑ road Improvements
Conditions /Com mentsr
•
Utilities:
N. 811 Jefferson
Conditions/Comments•
•
Other:
•
Plan Exam
Fire Prev.
Conditions / Comments •
IInformation ❑
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach condltlons relative to final as built approval
2 Indicate above or attach reasons for hold
1
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RQGfE4 yy Live
Hou.s ii/C/{ Suet firE:A/;
Sip -Ct /.4A/,l;
bor.sed Add, ,4,•