1984, 04-23 Permit App: 84A-3987 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 Name \ (last) (first) (m) IDepartment Use Only
_1bCAY� _�_ + PCS 11 I /V Res. ✓ I Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
S <C 313 4-
3 City/Community State
S PO kclV\ E1
Subdivision/ Plat Name
SON CG�d Jf� � �V� 1 J II C17/
4 Assessor Parcel No. {� q
`C
Lot
Block
DEPARTMENT USE ONLY
5 Sic Code
Zone Act. M J
Zone�� Project
No.
6 Dwell p
rr
No. of Buildings
Sq. Ft./Acre
Depth t
1
Frontage
7 Set Bade -Front t
(L)S-1
t2 �
(R)S-,
Rear,
Cbnsus Tract
Module No.
16 Ag
tett Firm Name
V40116
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
Contractor Firm Name
Ri�TZCT C d NS � t2UC�rea�
Street Address
7�`f N, 1140 I�
Zip
?, p/o 7
CityState
� � D� Gids
Phone
( ) '? -D- (,-, 07
Contact personL
L r+ 1
License No.
Phone If different than above
( )
8 Owner/ Agent (if different than M1 above)
Business Address
g Zip
City
State
Phone
12 Review Required
Plan Check (YIN)
Y5
Other (Y/N)SEPA
SGS
Exempt (Y/N)
\fcs 1
Date
15 Type Work Bldg
❑ Fire
❑ MHNew
❑ Demo
❑ Add/Alter
❑ Replace
❑ Move
ElOther
14 Describe Work e C C C', L Cil�l
10 AH nt Name
Street Address
11 Zip
90 —7
City-- qq1t
0f1� 0IrAv 44
State
,�,I f
Phone
( ) 2 v �o�
Lender -
W Ci `� ti t r� `t�� / v1(l 0.
Street Address
Zip
City
State
Phone
ltact Person
ve bneY,- or ynY�e `fov,h
Phone if different than above
Additional l n f ormat io n
DEPARTMENT APPROVALS
This is not a Permit
Application Type
(Standard unless (Indicated approvals required in either "release" or "release with conditions"
otherwise indicated) space prior to permit issuance.I
❑ Fast Track
❑ Early Start
Environmental Health ❑ Qbmmercial; CKResidential
W. 1101 College New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLIIC�®A"TION #
Conditions/ Comments: �/LKi✓1.1a,(/Lt�� vi �/Ji Gt/w���14'l�L
❑ Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
Engineers:
N. 811 Jefferson
Conditions/Com
❑ Utilities:
N. 811 Jefferson
Conditions/ Comments:
,—III
II Other:
Plan Exam
Fire Prev.
Conditions/ Comments:
a i
c
❑ Commercial;8' RR'sidential; ❑ Flood Plain;
El drainage knew access/ approach; ❑ fence;
❑ r,6ad improvements
-u
Project Representative
Cn Agencies Performing Special Inspection:
Y O 1'
U '-
►- E 2
L c
LL
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold
Release
Release w/cond 1
Hold 2
Telephone
9usow s oN POMPLAOSA
STeeeT S. toii(v 3' •1s
1.04& - 407' 9 stock I PovpjtosA I *K ADD.
3c)'5—"AVE. ST�Ecr
14
Uri