1984, 05-04 Permit App: 00000815 MH•
BUILDING PERMIT APPLICATION WORKSHEET
a 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 None (last) @N Use Only
�Cepmiment
sr, 1., M H' „
/e
Comm
2 Project Address) not Malting AddreM) ar Road Nam° Spare Zip
9r/ r) E ) M— f zoo
3 Oty!Community
Spa Ciznti
State
lam
Subdivision/ Ptat Name
_ a 1
a Amstar Parcel No. ZOm�7—
��Can n:c FYI D`)rIti
\(p( 1
ow '<—
Lot
�-
Block
}g /
a a A DEPARTMENT USEONLY a * *
( 5 Sic Cade
(Zone Act ft
I
Zone —
Project No.
( 6 Dwells
No. of Bull Inns
Sq. Ft./Acre
Depth'
(05
Frontage
t
IZ1S
7 Sat Be
Back -Fronto.
k
Z5
9 -IB -1
(5)5-2
s
Rear
Census Tract
Module No.
5
Initieie
59-
18 Architect Firm Name L I Street Address
CM
Slate
Phone
1 1
Contact Person
Phos If deferent than above
Contractor Firm Name
SAArile AS A3onC
Street Address
Zip
Oty
State
Phone
Isa5 4c-4-19 s1
Cant¢t Person
license No.
Phone 11 different than above
1 )
8 Owner/Agent (If different than (11 above)
Bus' em Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other(YIN)
I SEPA
sena CON)
Date
15 Type Work Bldg
❑ Fire
I MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
❑ Other
14 Describe Work/ r�
to OT("3615 2 -DoN B(.E LA> t b secs
��
3 0,E 1 146 �E pA1J/�rsTACL
10 Applicant NameA-lite
Street
Address
11 Zip
City
State
Phone
Lender
Street Address
DP
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Additional Information
Application Type
(Standard unless
herwlse Indicated)
ast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either 'release" or 'release with conditions"
space prior to permit Issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial; of Residential
C New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION q
•
Release
Release
w/cond 1
Hold 2
Conditions/Comments'
0
Planning/Zoning: D Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone'
O CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments'
0
Utilities:
N.811 Jefferson
Conditions / Comments•
0
Other:
Plan Exam
Fire Prev.
Cond glens /Comments•
Project Representative Telephone
Agencies Performing Special Inspection:
1
2.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold
52'-0
33'
3�0
9,1
9
24.0 % 28=o
z44o a 24'-0
Gel
DecK
.298 Sq.Fr
e .._it % -Ym..
251
•
1
/25'- o