1984, 09-12 Permit App: 00002245 Barn s
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 Name (last) (first) � (m) ropartmentUseOnly
i-.tf J S4:1 ` r A/� I (ZUi 1\J s. 1/ Comm
2 Project Address(not Mailing Address)ar Road Name Space Zip
3 City/Community State Subdivision/Plat Name
'F c (AN 'S AID D ( TCS!'`)
4 Assessor Parcel No. Lot Block
24-5 --2' -Jct * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone ( Project No.
MlZ 1
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Back-Front (L)S-1 (R)S-2 Rear Census Tract Module No. Ini' s
* *
16 Architect Firm Name Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
,
Contractor Firm Name Street Address
Zip City State Phone
( )
Contact Person License No. Phone If different than above
( )
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(YIN) Other(YIN) l)SERA Exempt(YIN) Date
15 Type Work ❑ Bldg 5 MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
10 Applicant Name Street Address
6 -8 :. 0 e-`-(' TA l_ --(3,41 Y eo
11 Zip City State Phone
g2 QC 4- ( )
* Lender JG/ Street Address *
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.)
❑ Fast Track
❑ Early Start Release
Release w/cond 1 Hold 2
El Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
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;
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
• Plan Exam
Fire Prey.
Conditions/Comments:
c__J
, Project Representative Telephone
0. Agencies Performing Special Inspection:
Y
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-
e cs
H E 2.
N o
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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