1984, 05-10 Permit App: 00001385 Garage 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 OwnerV \ (last) \!- , ' (first) 1(m) Repartment 11 Only
\1� � _`�`}t Ids. ✓ Comm
2 Project Address(not Mailing Address)a'Road Name Space , Zip
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3 City/Community State Subdivision;Plat Name
1—÷---(446uJ 74 ( l'AK-\c
4 Assessor Parcel No. Lot Block
o/_5 4-z D70-z- go cc, * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.k Zone Project No.
6 Dwell 4 No.of Buildings Sq.Ft./Acre Depth Frontage
�.._2__ ZS oc)443 l Z'S i.Esc
7 Set Backk Ffpntr I(L)S-1 I (R)S-2� RearCensus Tract Module No. 'l> lals .
* 16 Ar Firmtame I Street Address *
Zip City State Phone
( )
Contact Person Phone If different than above
( )
CoQlrictof tl' Sv:: :t_;\\____N Street Address
1.1 Zip City State Phone
( ) c(,24- 378 7
Contact Person License No. Phone if different than above
8 Owner/Agent(if different than 41 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Othe`�r /N) ISEPA Exempt(YIN) Date
15 Type Work V Bldg ❑ MH New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
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10 Ap nt NanirStreet Address
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11 Zip City State Phone
( )
* 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.)
fl Fast Track
❑
Early Start xRelease
Release w/cond 1 Hold 2
Environmental Health ❑ Commercial; �' Residential l /� .r
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition v, /-t S. �IY�6i
Room 200
El structure; 777
APPLICATION#
Conditions/Comments:
O Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; El lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
El Other
Conditions/Comments:
Engineers: ❑ Commercial; Q esidential; El Flood Plain; ��
. N.811 Jefferson ❑ drainage new access/approach; ❑ fence; �' // "�
9 ,
El road improvements
Conditions/Comments:
D Utilities:
N.811 Jefferson
Conditions/Comments:
CI
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
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en
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--❑ Project Representative Telephone
fa Agencies Performing Special Inspection:
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1` E 2.
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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
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