1984, 04-30 Permit App: 00000100 ResidenceX2`1 2-5--(�
IDs
BUILDING PERMIT, APPLICATION WORKSHEET
.PLEASE PFI NT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this urlginal end your building plans to the Department of Building and Safety)
1 Ownera Name / pot)
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2 Project Address(netts/win9 Addrma
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3 grylCarnmunlly
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Subdivision/PlatName/
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4 I No.
2453-17
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55n
Blecke
3
w * DEPARTMENT USE ONLY * * *
5 Sic Me
Zone Atte
Project No.
6 Dwell N
No. of Buildings F
Sq. Ft./Acre
Depth
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Frontage
Qt.'
7 Set Bak -Front 4
Z5
(L)S-1 ,
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(R)S-21
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10 Architect Firm Nine ' " '.e I Street Address
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City
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Phone
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Phone if different than above
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Mtr "Firm ,(p04)5764;„)
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Address L_4
4/77y
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as Address
9 Zip
City '
State
Phone
1 1
12 Review Required
Plan
Bleck lYl
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Other (YJN)KC7 ISE A
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xempt (YIN)
Date
15 Type Work Sr
0
Bldg ❑ MH
Fire "❑ Demo
41' New
❑ Add/Alter
0 Replace 0 Other
0 Move
14 Describe brk
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10 APPllcant Nam'
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State
Phone
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Phone If different than above
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Additional information
Application Type
(Standard unless
otherwise Indicated)
est Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either 'release' or 'release with conditions'
apace prior to permit Issuance.)
Environmental Health
W. 1101 College
Room 200
❑rrommerclal; 6 Residential
l3 New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION ft
Release
Release w/cond 1 Hold 2
atrII �-
Conditions/ Comments'
Planning/Zoning: 0 Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot alze; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions / Comments
Engineers: 0 Commercial; %sidentlal;
N.811 Jefferson El drainage
��
O road improvements
Conditions/Comments
new access/approach;
17 Flood Plain;y
0 fence,
Utilities:
N.811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
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
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