1984, 05-16 Permit App: 00000233 AdditionBUILDING 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 Nem,yqpy Deva /j / no -et) �} )
Rl(<Y1111Bnt Use Only
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Comm
2 Project Address (not Mailing Address) a Road Name Space,Zlp
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Stateeil4.
$ebd.S�•V#4S Ae(c/i7e Al
a AMMO.' Parcel No. �{
2453 —oifa
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DEPARTMENT USE ONLY * f •
5 Sic Wk Zane Act. If
Zone
Project No.
SF
'
z33
6 DwellNo.
t1
of Bulldigps
Sq. FL /Awe
Depth I
121
Frontage
f2o'
7 Set Back{ ont
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IMS -1
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19.5
1
Reel
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Onsus Tract
Module No.
Initials
.loti) m
16 Architect Firm Name I Street A dress
Zip
Gty IState
Phone
1 )
Phone If different than above
1 )
Contact Person
/
Firm Name
Co, I '`t' 4001087:4001087:°
C � a)
P�/
Street Address
Zip
.10444 vl
State
404.
Phone
IJ �/�
) g711.5 `J,40
Contact Person
License No.
Phone a different than above
8 Owner/Agent (Il different than p1 above)—
Busl ess Address
9 Zip
City
State
Phone
I
12 Review Required
Pia
Check (YI N)
Oth r(YIN)
I BEPA Exempt (YIN)
Date
15 Type Work 'Bldg
0
Fire
0 MH
0 Demo
0 New
Add/Aller
0 Replace
0 Move
0 Other
14 Describe Work
l�VI�D0
6 �
10 Applicant Name
�l yV,ivrC
reetAd�
Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
(
Contact Person
Phone if different than above
Additional Information
PE -06 IvX4r` = 491
log- . (4X24 = 33G�
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
Environmental Heap
W. 1101 College.
Roots 200"
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required In either "release' or 'release with conditions'
apace prior to permit Issuance.)
0 Commercial; fg/ResIdentlal
�❑. yew Cunstrucl:Ipftj, , ❑',Bidd',pteration(s6ditlon
• Additional ssrructture;
• APPLICATION $'"+/•1• '�� •`�^
❑� •;a-
Release
h
Release
w/cond 1
Hold 2
9 j
.
Conditions/Comments' ♦"�.k
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
❑ Setbacks; 0 lot w/d; ❑ lot slze; ❑ use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/ Comments•
Engineers:
N.811 Jefferson
❑ Commercial;
❑ drainage
❑ road Improvements
❑ Residential;
❑ new access/approach;
❑ Flood Plain;
❑ fence;
Conditions/Comments' j
Utilities:
N. 811 Jefferson
Conditians/Comments•
Other:
0
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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