Sprague E 11723 Kenneth Toevs - Sign
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BUILDIPIG PERMiT APPLICATION WORKSHEET
PLEASE PRINT AfVD COMPLETE ONLY THOSE PARTS OF THE FORM YOD UNDERSTAND
(Please return thls o►Iglnel and your bulld(ng plane to the Department of Budding end Satety)
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~ ownera N e (last) plret) ~m1 oepertrnent use oMy /
i~8 Comm "
~ PbleCt Ad&eA _(n01 Mailing Addres9) ar RCad N8►ne Spam ZiP
IUZ5 -
3 GtylGwanunlty 8tate - Subdlvl Piat Name
a Pilroel No Lot 8lock
- C~ ~..^2 0 ~ DEPAATMEN7 USE O(JLV * • ♦
5 Stc Gbde 7on0 Act 9 Zwe (J01r1 " P►oqec/ No
6 Dwel10 No Vulldinge Sq Ft /Acre Depth Frantage
7 Set Back-Front (l)8-1 (R19-2 I~wu Oansus Trect Madule tYO Inittals
EX t 547 nr G CA.t t,v
+ 18 Ardilteat Flnn Nome Street Addresa ~
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Zip pry stere Phone
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Qwtac! P+erson PiiORe It dlt/e►enl IhBn ebove
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Coniractor Flrm Name St►aet /Mdrm
~''1 A R~ ~L516 Al S, , -E,
zio pty Stete Phorta
30,0" nj ~ ~ L` r~ c ► a9D ~
C.ontect p4argm UCer~ee Pharte 11 dllierent than above
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g pWnerlAgent (if dlHerent ftian 01 above) Bueiness AOdrsss
~ g 7jp Cify ~ Siete Phone
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12 Revtew Requlred Wan Cheak (Y/N) Otner (Y/N) SEPA Ezempt (Y/N) Date
IS Type Work ❑ 81dg ❑ MH C] New n Replase _ Oth~.
~re 0 Dorteo O Add/Alter 0 Move N '
14 DesGrlbe Wo►k -
1~~ c :EJA a D i nrG- Sf Et,t ~ fr.~~Pi4 l- S/G&
tQ Apptlesnt Neme Street Address
t t Dp Clty Slale Phone
~ Lendet - Street Add►ess . ~
2io City 81ate Phnne -
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Conlect Persan Ptlono 11 dflferr*nt, timn above
AdrJIiIbnai Infprrttation
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DEPARTMEIVT APPROV14LS
- This is not a Permi#
Appllcaf(on Type
(Standard unle$a (Indicated approvals requlred tn either "release" or "release witA cpndttlons•
otherwise Irt0lcated) spacre prlor to permit iasuance ) -
Faet Trsck
Release
Early Star,t, Release w/cand 1 Hold 2
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Q Environmenta! Health ❑ Commerclel; p Resident(al ~
W ttfl/ Callege O New Conatructlon, p 8fdg elteratlon/addition
' Aoom 200 O Addtttonai etruoture, _
APPLICATION 0
Conditlona/Comments -
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JP1- Plenning/Zoning• 0 Commerctal; ❑ Cert of Exemptton, D Frontage, ~
N 721 Jetterson O Setbacics., 0 lot w1d. O lot aize. 13 use/zone,
O CU, varlanoe, zone chenge, ahoreline; O fence,
thet .
conditionsrCommente 7VG'
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~ Engtneers: O Commerclal;, 0 Residentlal, D Fiood Plain,
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N,811,Jeflerson C'J drainage r-I new accesslapproaah, O fence,
Q` roa innprovements '
CondltlonslComments ~ ~ 0=- &,'ael
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utiuuss:
N. 811 dettersan
Conditlons/Commente: -
Fl Other. _
~ Plan Exem
FI►e Prev
Condltion8/Comments - - -
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Pro)ect Representative Telephone _
~ Agencie9 Performing Spectal Inspactlon
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Y 0
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f- E 2
3
1 Indkste ebove or atlach cottdittons reletlve to final'ee bulit epprovel
2 Indketo ebove or ettach reasona for hold
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