1984, 12-17 Permit App: 00003743 Wood Stove -24 , 31 --146 .
BUILDING PERMIT APPLICATION WORKSHEET z
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 Com-,.��(last) (first) (m) I Department Use Only
.SCAe�da/ `/ e/2/1101( f3s. Comm
2 Project Address(not Mailing Address)or Road Name Space Zip
706::. /z z2! F92-/Z__
3 City/Community State i i Subdivision/Plat Name
4 Assessor Parcel No. Lot I Block
i I 4 3 - 0 3 21 17, * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No.
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Bads-Front I(L)S-1 (R)S-2 l Rear Census Tract I Module No. Initials
f
* 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) ISEPA Exempt(Y/N) Date
.
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace 7. Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
woof) -1-tiv
10 Applicant Name Street Address
11 Zip City State Phone
Cle?' 72 ego°
* *
Lender 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
❑w Environmental Health LI 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:
a
C
Project Representative Telephone
�a Agencies Performing Special Inspection:
Y O 1.
c0
E 2.
OC
LL
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold