1984, 08-09 Permit App: 00001685 Garage .F
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)
1/�, Department :- • ly
2 Project Address(not Mailing Address)�� fS n "`�� e S Comm
G Rodd ame Space
L/D [� _ c �.C_, AV qZip
3 City/Community aO State 1_Q
''nn 1 Subdivision/plat Name
lJek w& G` L.-) 1'" v rC...erTC5±--
4 Assessor Parcel No. Lot
l) 1 I Block
�" t_. ZCi2s4{-2OC?g a * * * DEPARTMENT USE ONLY ,t * *
5 Sic Code 1 Zone Act.* I Zone
g IZ. Project No. 1/
8
6 Dwell k No.of Buildings
I
"2— Sq.Ft./Acre I Depth Froe
7 Set Back-Front 02 1 `'ZO. G g S i
(L)S-1 l(R)S-2 ` [Rear , Census Tract i Module No.
Initi�}g S
* 16 Architect Firm Name (,!1 C
C e'� I Street Address *
Zip I City
I State Phone
Contact Person ( )
Phone if different than above
Contractor Firm Name
Street Address
Zip I City
I State Phone( )
Contact Person
I License No. Phone If different than above
8 Owner/Agent(if different than k1 above)
I Business Address
9 Zip I City
IState I Phone
12 Review Required I Plan Check(y�� Other /N ( )
Y I '/(Y ) J SEPA Exempt(Y/N) I Date
C �
15 Type Work J(Bldg I D MH I
EV/New I ❑ Replace I ❑ Other
0 Fire ❑ Demo 0 Add/Alter
14 Describe Work 0 Move
T €D Gla( ,, (24 x.30 71 Q
Izf
10 Applica t Name J
/t 7 QStreet Addressdr �`
11 Zip Lal VcAll-- ev`SOf\ 4bD-)- E a0
City I State
CI q r 4 w\ Phone
Lender
I Street Address *
Zip r` A.
1City I 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.) f
❑ Fast Track Release
❑ Early Start Release w/cond 1 Hold 2
VEnvironmental Health ❑ Co mercial; residential
W.1101 College ❑ ww Construction; ❑ Bldg alteration/addition -2.-211
Room 200 Additional structure;
APPLICATION#
Conditions/Comments:
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage; I I I
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
0 CU,variance,zone change;shoreline; 0 fence;
0 Other
Conditions/Comments:
gill
12/Engineers:
❑ Commercial; • / I I
idential; 0 Flood Plain; r�
N.811 Jefferson 0 drainage new access/approach; 0 fence;
❑ yeld.improvements � /�' � 1 .
Conditions/Comments: l X�/�� 'S'' -C'"1i ` ,`
❑ Utilities: I I I
N.811 Jefferson
Conditions/Comments:
❑ i I 1 I
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
ci
co
c❑
is
Telephone
Project Representative
a Agencies Performing Special Inspection:
co
1 o 1.
C.) '-
N as
t 2.
N O
co LL
E
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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