1984, 08-24 Permit App: 00001942 Residence Q_..►
BUILDING PERMIT APPLICATION WORKSHEET '
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU U DERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name / (last) T (first) (m) I Department Use Only
/ l:L!/ /ui'I q .l_.i'1Ca _ s. ✓ Comm
2 Project Address(not Mailing Address)or RiadName Space Zip
E . ►%321 �-c" AVG . Qq. Zo
• 3 City/Community State Subdivision/Plat Name
l )1 • Hoy. it,Ja±e. , ILId v
4 Assessor Parcel No. 1932 Lot Block
0.1/5513 --0 / O 6 / * * * DEPARTMENT USE ONLY
5 Sic Code Zone Act.# Zone Project No. I 4142.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/ / /aY /002
7 Se��jk-Fron , I(L)S-1 �, (R)S-2 t I Rear Census Tract I Module No. �I�
* 16 Architect Firm Name , 7.-(=>)
d Street Address \�}J
Des,YJ 11 4%/i i a r1� li_ 2'ne5
Zip City State� 11 Phone
9�0 6 04-a n c- Ex,/17 . ( )
Contact Person Phone if different than above
bra 4/ r-614•5 ( ) ,
Contractor Firm Name ,i Sc. /a; n ne_ , Street Address
J .. /0 /moo A 62.3s---
Zip City 1 State,, /I Phone
990006 ;�opkahc A. n • (-5b ) 9oz6 075
Contact Person V License No. Phone if different than above
al,b /'e �t,cJcZ h 56 n D 8-BGC Z ,,/(1/243 ( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) ISEPA Exempt(YIN) Date
`65 YE S
15 Type Work d Bldg 0 MH }i( New 0 Replace 0 Other
/T c,...) Was cue n t ,,..7 Fire 0 Demo 0 Add/Alter 0 Move
14 Describe Work l�
10 Applicant Name Street Address
5a./ric a_ bovc.,
11 Zip City State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
ddt nal Informationa
o j 3
i !
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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.)
❑ Fast Track
❑ Early Start Release
Release w/cond 1 Hold 2
❑ Environmental Health ❑ Commercial; ❑ Residential
tiktfW.1101 College ❑ New Construction; ❑ Bldg alteration/additionRoom 200 ❑ Additional str[uccture/; �J ���
APPLICATION# c'rT !6.0/
Conditions/Comments: 4-/L..-4/-7 �z ��I fJ�`�.
❑ 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:
0 Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; g g
N.811 Jefferson ❑ drainage ❑ new access/approach; El fence; . , I
❑ road improvements
Conditions/Comments: % 2 41
0 Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
0 Plan Exam / ' /.
Fire Prey.
?-47Y"4-
Conditions/Comments:
O.
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❑ Project Representative
Telephone
o. Agencies Performing Special Inspection:
co
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i E 2.
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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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