HomeMy WebLinkAboutPines S 123 Change of Use
(THIS tS NOTA PERMfT)
.
BUILDING PERMIT APPLICATION WORKSHEET ~
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOD UNDERSTAND
COMPLETE IN {NK
, (Please ►eturn this otiginal and your building ptans to the Departmenl of 8ullding and Safety)
SHADEO AREAS ARE FOR OEPARTMENTAL USE ~jed Nismber ~
~ p~rner~sl~lame LqST FIRST MI
f 9)9;/
ProJeCt Addren (Street Name 8 Number) ZtD
~3 r~ 27~1
rAWNk=t
p-p •nx Q'o~G
~l~n/ S~te D
sPQ~ P~o'e v~'~) 4 .
°9
I ~~ness Pfme
tWtreotcrJAgFA A ~ L nddre+ss
V~ L
G1y State Zip Pl~ot►e
I f
ppnteat Lkem8 NumD[u (Repuired) Bustness Phone
I 1
,
NcftltedtF.npfneer A,ddress
qty State Zip Whone
t 1
8usiness Phone
Lotdor ~ Add~ ~
~p Phm
( I
I
~j~`~~~$~~IpPt^~~.jo~♦ ~d ~t V ~ x~•~~ 0~~ f p~s~oZ~-~'e►v~'s~j+`- ~R•~tVr`~-_ ~wn~un./~Ss`~. °
/ y
~ ~ J• ~~~1 Y 1
' p e d ~ l~ ~ ~►►~D w~«~ S M►o~ . _ ~ ,m,. ~ ~ , r e
► ' . ~ ~ ~ r r ^`C" ? r r`~ ■
n~ ?7~
il' " ~ '~'~^''~-.c'"'TF,~.,~~~•,\d ~',C~ ~ A ~'Lyr~' a~l-i.~~.-,' *{~~'~>o. !~g7' :y^r~~~~t+F'~l'
~ ~ Ta ~ J - ~ . _ - ".r`-_.-,r, ~ Q ,,.,t y.~'~ • D R, ~1 ~ i44~+
T-Y^
, 1 ' ~ A* ■
~~~t~~ R~~g•'K.~ ~ ~ ~ L ~tryd' Plat tUauw
~ ~ f . „~!N♦ 2iI 1 I.~ ♦ ~ c .si
ic>~ o > r ~ ~ • n r p • y i ~ ~ ~ a ~ / o .►!a
~ ~^f ' /r
~
PI~t1`_ ..~,•~t 08t~STrBd
2A7te ~T1p
Cp
i'~11~~ r~• ~,'S~ ~ r~q ~ ~ ~ ~ ✓
M ~ ► 1
,7 R.~S ~ ~11I~0~ 8N~b1fIQa~1' ~ 3 ~ ~ LM SLB (5Q. FL/AM) ~ ' J r•'~' DOPul t Z 4sp. ` 4 FfOf1tw .
f4 tY~ . s~ Q ~ ~ s~,~~ ~ . ~.i?"' ~ ~ ~ °V ° y 4 ti.r' ~E ~ ~'~►'Vavl~~ ~aO ~7t~'yi ~ 1 ~8~~/i~~P`''„~ ~ '
~y r t c
~AMkWW* R/W WIdpH~'~ ~'i~ I
}}tr°R~ , 1~d~raid 41Y~ ~ ° + ~ ~'Ctic~M~~^~r ~7~` ~ • t 1~ i~`~~t
Ft y~t
'~~J~' y~
/ ~ ~ '~14~~ '1~~ ♦ ~o4 I ~
i •,r`..r~j- •1('F„r, ~ , ~'~~•S `~!t` t ry~,..,~.~.~r,71~+ S 'r' T0~ ~ ~Y«F A ~ ^ ; '°^:Y
. j • ~ ~ ~ ntLxB ~ ~r~q ~`l"i~~t ~ ~r > ok 7s~4 ~
v ~ 1 ~ ~ ♦ -~i P d ~ n e~ t
, ~ ~ 1~r , ~~y~~d cft/~" Y ~ ~''~°'~•~C'laI ~ ~~i~~t ♦ Y ~1~:~ !'~'~~YStL'+f1f~J\~4li~~ ~
~~~jb~~;~~~rT''`,. ~Y►b;,~ ~ 4+~-41.~° `KM ~ i
k'I~ ~ti~--~ ~tr,.` j y~~ 7F#a ~ ~ 4~,{ i ri fy~~
~E. „ s ~ . d ~a ~o , ♦ ~i
~ ♦ ~p ~ j~ 1~-i1 ♦ y ~ `f ~ J
q rw~ .r' 7 ~1 { ~.I ~ l~ s~y r J 4 y T~ Z ~S~'v~' 4 I a ~ ~ ~ D ^ G.
~+t f. : ti~T-~' . ' rr p~uJC a • ~ . ~ ~ _ ~ ' e ^
r te , f,,,, t~I~f ,•C ~ ~y__`J tJS.'1~ } 4} ~ ~r~~~_._~ * ~ f~ s= y°Fc~i 3`''~F'
P
nn. IT~ 4.f.
ry~'rC ~'~'~f
F xid'F~S `~M~✓ rl h ~o Q♦ w ~ n~p af ah/~} ~ p tray;[ 'tf` *~i Z
'4 i~x j y o~~~` a ~ , C' ~ c Q 1' • d ~
S I i
~~v X~r • ~d 3~ ~ N. b i 9 o • 1 ~ ~ ~ ? . a~ v
♦ "'~°'4 ~ `d~c'V '1r D+~ w~L ~ ~ ; y ; S i+t~~ y„ i
D
1'
o
t~ l~n 4S C 4' , ~ f e ~ a ~ ~t M
pe„~rin-ro • -
~~4~yy ~k~ j ~_~r~A,I +'~~.~Y ' °t'~ L 3~,ttyF".o•~~~~~` ~ Y~+ i,~ i ` . p°~~ f~ ~ a o
r i S'~`~1~ ±1~`~Kti~ ~d.. br + -'`'~c`~ _ ~~1 v~4 `]r~ ~ ~j ~ ~ t ~ ✓ 0.~~~
~ ~~~rb.~!7a..'R-•`~Y~+~'.'~ ~ ~ w • ~ 7~..d. ~M~~ ?
Y~ lk • . . ^ ~ ~ `14 r '1
r-~ .rV"
~ 4~ ~~a! t ~ . ° . r^~ Y ~ p~ ~ ~ • ~ `1 e
~o I r
~ r . I . . . ~ . . . . , i~ ".w~~...__'~1F^R~ . .
DEPARTMENTAL AE1/IEW
' Cond. ' .
Hold
Approved APPr~ai
ti . Emlroementel He81th Appilcatlon f
W.1101 Collepe jeA
, Aoom 200
r
C7 6
Planntne/Zonlne 1 `
, N. 721 Jeffereon
, , .
r
'
Enelneero
N. 811 JeNerBOn ~
UtUiHes
' N. 811 deNerson ~
V 1
Plan Rev[sw/Firo Preventlon
❑ N.81t Jefterson _
~o T~~GC~ Foca. Am. OTiowa.sA-
Odw ($EPA/Ctitkal Nleftttaf/ft.)
❑
- '
Q FaN Tn~elc/"W Ins"o fn nformatlon
~ Prqeat Representatlve - ~ '
Phone ~
Addrm
~ I oertlfy that I have examined this applicatlon and etate that the Informatlon contalned In It and eubmitted
° by me ar my agent to oomplle sald appitcatlon Is true and correct.
~Ipnature Oate
~