1984, 04-18 Permit App: 84A-3599 ResidenceBUILDING 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 a
:?�_
(last) first)
�— z� –�_,
(m)
Department Only
Pas. Comm
2 Project Address (not M iling Address) or Road Name` aj Space
Zip
3 City/Community
State
Subdivision/ Plat Name
4
4 Assessor Parcel No.
(
l
Lot I Block
DEPARTMENT USE ONLY t rr +
5 Sic Code
i'
Zone Act. M
Zone Project
No.
6 Dwell M
No. of Building
Sq. Ft./ Acre
Depth
1 ,�,
Frontage
8'1
7 Set Back -Front
'
(L)S-1
t i
(R)S-2
^
{
Rear _
Census Tract
Module No.
Init'
✓/
16 Ar' Tt Firm Name
Street Address )
Zip
eft 6
City fr,
State
Phone
-z e �-
Contact Person
Phone if different than above
^Co twjor 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 (Y/N)
(�
Oth`e'r (Y/N) SE
>
PA Exempt (Y/N)
Date
15 Type Work
Bldg
ElFire
❑ MHX
❑ Demo
New
❑ Add/Alter
[7Replace
❑ Move
❑ Other
14 Describe Work
10 Applicant am
Street Address
11 Z
/ '7'-Z& (S /
City
[ 1
State
_,., "
Phone
I ) 7,;a4�;
Lender/
Street Address
JS" -p
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
1 1110 IJ I IVL Q rGl IIIA
Application Type
(Standard unless
(Indicated approvals required in either "release" or "release with conditions"
otherwise indicated)
space prior to permit issuance.)
]
Fast Track
Release
]
Early Start
Release w/cond 1 Hold 2
Environmental Health
❑ 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;
❑ CLI, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson
❑ drainage ❑ new access/ approach; ❑ fence;
❑ oad i gro ements i
Conditions/Comme ts:
El
utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
El
Plan Exam
Fire Prev.
Conditions/ Comments:
L
1
i
Project Representative
Telephone
L
Agencies Performing Special
Inspection:
1
c
1.
o
m
E
2
0
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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