1984, 09-12 Permit App: 00002241 GarageBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your Du lid Ing plans to the Department of Building and Safety)
1
Camer'sNemo
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(m)
1 Y 777 91 7
F®rtUst
Po. Comm
2
RPt A,7 (not M liy Ad&2� v Name
CG
Spac
Fir
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etetp _
SULylylione,Plat Neme
Lj u
a
Avr®cr PlarrelNo.
_3
Lot
Block
♦ : ♦ PARTMENT USE ONLY ♦ ♦
5
Sic Cada
Zone Agl.N
Zone rryA.If ,, N II Prolect No.
S
Dai /
No. of Sold l
Sal=Ll Acre0 0
Depthi
FTortii 0
T
Set Bait -Fran
/03
(yS-1
(RIS-2Rear
3S
3
(bn9ue Tried
MWUI. Np.
Initlale
16
Aret Firm Name
Street Addrae
ZipGtr
slate
Phone
Ourne, Porxn
Phone B dinoment then a move
1 1
acbr Flrm Name
Street Mariana
Z9 %o206
Gry n
sln�Q
Prom l
9ae- as 9 G
runtay Peron
ueenee No.
ift
pri
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Phone a dubrem man above
S
nerl Agent til different than Ml improve)
I liueineas Address
9
Zip
City
State
-one
1
12
Revlew Required
Plan Cha, lYl N)
Other (Yl N) SERA
Exempt (Y/N)
ate
15
Type Work
Bldg
G Fire
J MM
"l IRmo
C New
C qdd/Alter
0 Replace
❑ Move
C Ohller
1C
�scrlda Work
02o a
'IF ir;
10
Applicant Name
Street Addrae
11
Zip
Cily
State
Poona
Roper
Street Addrme
Zip
Lily
Stale
Ppone
CAntazt PMaa
Phone it dlflerent man above
1 )
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
I nls is not a Permit
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release'or^release with conditloW
space prior to permit issuance.)
❑
Early Start
Rel ase
Ral w and 1 Hold 2
Environmental Health
W. 1101 College
Room 200
❑ Commercial; ❑ Residential
C New Construction; ❑ Bldg alteration I addition
❑ Additionaluc(/tTyuur�re;/r� ygr
L '
AP LICATIO V
Conditions/ Comments:
❑
Planning/Zoning:
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson
❑ Setbacks; ❑ lot w/o; ❑ lot size; ❑ uselzone;
❑ CU, variance, zonechange; shoreline; ❑ fence;
❑ Other
Condit Ions l Comments:
❑
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson
El drainage ❑ newaccess/approach; 11 fence,
❑ road improvements
Conditions / Comments:
❑
Utilities:
N. 811 Jefferson
Conditions / Com men ts:
❑
Other:
❑
Plan Exam
Fire Pre,
Conditions / Comments:
❑
Project Representative
Telephone
Agencies Performing Special Inspection:
1.
E
2
IE
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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