1984, 10-25 Permit App: 00002951 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)
(fast)
1 Owner's NameDepartment Only
(first) (m)
,4
7://)//1 -Al /PPA/19T f Ras.
//N
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
X114 77-
3 City/Community
...17- 0 /r-41 iv?,
State
r.--1../././
N
Subdivision/ Platame 3/ L'
SP-
p_FL, -
4 Assessor Parcel No.ep-rry (y
..3-(310 }
Lot
'Block
* ,t ,t DEPARTMENT USE ONLY
255 1 CLOM- �{ Y�T ,
)
5 Sic Code
Zone Act. if /
Zone
AGS,,
Project No.
2 5`/
6 Dwell N
/
No. of Buildings
/
Sq. Ft./Acre
IA
Depth
L25
Frontage
150'
7 Set Bads -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
F5*
16 Architect Firm Name
I Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different than 91 above)
Business
Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan CtIck
vvjj
Other IN) ESEPA Exempt (Y/N)
VC, --'
Date
15 Type Work ly Bldg
0 Fire
C MH
0 Demo
trNew
C Add/Alter
C Replace
0 Move
❑ Other
14 Describe Work ��`
lieSr
C%eb. 0 l 7,6 j� &C�7 te`1 C�/
10
- O11/1i19/cam (7--- I.// trd.-ti
Street Address
7-10 3 N war�474-
11 Zip
79,Z/ 7
City
-- 11-o
State
z�
Phone
( 1 /2/9/J _ V'sy 7333
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
/7 q7 MF 0338
izcio uri
3S1/ all,
7
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either "release" or "release with condition"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ �Commerclal; 'Residential
New Construction; 0 Bldg alteration/addition
❑ Additional structure;
APPLICATION N
gal- ia.SS
•\ e,
Release
Release
w/cond 1
Hold 2
0
6 ®/"
of
-
Conditions/Comments' -4 &&. ,LQ/-1-/.di7 ree: 1$40,—e17/ -‘12—e
LI Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; ❑ Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; ❑ use/zone'
❑, CU, variance, zone chane; shoreline; 0 fegce;
/ Other SkkOR t ¶t4 tt
Conditions/ C a ts'
Sit- 69- 310 t
Fd'
i01 i.�I�
0
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain
N. 811 Jefferson ❑ drainage ❑,qew access/approach; ❑ fence,
0 road improvements
Conditions/Cr ` ezzAt
•
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
Plan Exam
Fire Prev.
/O//el/A
/1:(Ma
Conditions /Comments'
Project Representative Telephone
Agencies Performing Special Inspection:
1
2.
3
1 Indicate above or attach condition relative to Ilnal as built approval
2 Indkate above or attach reasons for hold
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