1984, 06-19 Permit App: 00000800 Carport BUILDING 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
' (last)NName (first) (m) Department ly
i 4 ri . k o I Res. 1 Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
GQ� l�
3 City/Community®unity State Subdivision/Plat Name
s, roe 1
4 Assessor Parcel No. LotBlock
16//_' —C(r):.1q I * * * DEPARTMENT USE ONLY * * *
5 Sic Code -� Zone Act.# Zone Project No.
6 Dwell# No.of Buildings Sq.Ft.lAcreDeptZ� h�--� Frontage
7 Set Back-Front 1(L)S-1 (R)S-2 f l Rear Census Tract Module No. Is
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* 16 Architect Firm Name 5 Street Address (\ /\
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name c Street Address „L
U4-ki I, ant_ U �-6 l { O O
Zip Cit State „/^C��L /� Phone /f 0 O ? 7'
�C//J// ,r/C/0 _ ((/y
Contact n L Phone if different than above
ecsr_
EC.132/2 C- ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check `jIN) Other(YIN) J
SEPAExempt(Y/N) Date
' VC S
15 Type WorBldg ❑ MH ❑ N ❑ Replace ❑ Other
C� 4 i ❑ Fire 1=1Demo • Add/Alter ❑ Move
14 •- Work / IA -
%,,49. 4 . l S'! Cl_l >14 )) '440
10 Applicant Name Street Address
11 Zip City State Phone
( )
*
Lender , Q Street Address
AC,c�/ `--`_
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
This is nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
IEI Fast Track
El Early Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; Residential
W.1101 College ❑ New Construction; Bldg alteration/addition /P
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone; .
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; I
N.811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
❑ road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
a
h
❑ Project Representative Telephone
ca Agencies Performing Special Inspection:
c 1
Y O
U '
i- E 2.
f0 w
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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Pick Up and Delivery, Of Course
We Replace House Glass& Building Glass,Too!