SPRAGUE E 7103 ERWIN SCHUBACH
BUII.DING PERMI`fi A►PPLIC►4T1ON V'VDFtKSHEET
PLEASE PRI NT AND CQNiPLETE ONLY THQSE PARTS OF THE FORM YOU UMIDERSTAN D
(P16a5e returrr thls origln81 and your buirding plans to #he Department at Sufilding and Safety)
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r 1 O+un$r'a ~varne f (last) (fkrst) fM1 C1apartmenR Us~ Orrly
Fbs M.
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2 PI`ojeC7,n.. Nlailang Address) p' Name ~ 5p2Ce zap
'2 7103C
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3pdSYlCdam ity ~ 5ta5ubdlvlsionlPdat Name
2-., 'e- -V~=P
` 4~,~sassar Parcel No . Lvt 8lack
FY * * dk ❑EPARTMENT USE ONLY
5 Sic Cvde Zone Act N Zone Proj6G# NO
~
$ t~vell Na vf Bulldlng9 Sq F# f~fe I~epth FrOntage
7 Sek B~k-Frqnt (L)S-'E 4R}S-2 Rear ConsusTract Nl~dule No Ini~
~ 18 11rrhRec# Firm Name Street Address *
ZIp Clty State Phone ~
f 1
Cantact Person ~ F}tidne if dlfferenl th$n abQVe
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C;qntractar Firrn IName 5lreet Addrdas
ZIp C##y state ~ Ptrane
Ccntaa# Pergon Licanse 1+lo Phone if tiiFferent than abrn+e
( Y
-km
gOwn$r~Agent 9 f dlfferen# Ihan Mt abo3re) Buslneas Address
~ s Zip CEty siare Pnone .
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42 IRevp&kw Requrred Plan Check (YJ N) O#her (Yi N) LSEPA Exemp4 (YI N7 Dats
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15 Type 1Nork Bidg u MH Q M9w 'I Replace f:~ther
Cl Flre Q Dema NI"'AddJ,Alter ❑ Mava
14 [Sescrlbe V►lork
CC>~.~- T~~ e'k) C., W i2_
M..~...~
]D Applir.ani Marne Streei Address
0 W k) t:--~ _ !52_7
11 ZCp Cfty 5tate Phane
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* Lentler Streel Address #
71p . Glty 5fiats Phane
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ContaC1 P9rsvn pMOnB if [}if{9r£nF thar5 dbGv@
Additional Infarmatiarr
DEPARTMENT APPRO11ALS
This is no# a Permit
Applicalfon Type
(Standard unfess (indfca#eri approrrals required in efther "release" ar "reFease ►nrith conditions"
o#herwise fndicated) space privr #a perrn#t issuance.) ~
~ Fast TraCk '
~ Early Start Release '
ReIease wlcand 1 Fiold 2
Envirortmental Health p Camrrfercial, ❑ Residential
W 1101 Ccrllege p N$u►r CQns4ruction, 0 Bldg aI#aratfonJadditi4n
Room 200 0 Additional s#ructure,
APRLICATIDN!d
ConBi tiansI Cvrn rnen #s-
'
~ Rianningf2anfng: 0 Camrrtercial, CJ Cert af Exemptivn, C] Frnn#age;
~
N 721 Jeffersnn ❑ seteacks; ❑ lot wrd, ❑ lot size, ouse/zone,
0 CfJ, varEance, zane change; shorellne, afence,
❑ her
Conditforr9lCornments.
~ _ ~ ~
~ Engfrrser's: ❑ Commerclaf; Residential; D Flaod Pla(n;
N 811 Jefferson ❑ drainage CJ newaccesslapproach; Cp fence.
. D road improvements / r
CnnditionslComments: ~ ~ e--
4 v `
Ll
N. 811 Jefferson
C.ondi tPona l Cvrn men ts:
~ Diher:
~
Plan Exsrn ~
Fire Prev. ~ GondtVons f Comments
~i, - -
~ ,
C
FO ProJect Representative Telspfione
~ Agencies Per#orrning Specfal Inspectlan
~
x a
Q
~
~ E
2
~ ~ -
3
1 Indlcate abvve or at#ach cortdltivns relatlve ta Ilrtal as buHt approval
2 Indkafe abave ar $t#ach re$sons for hvld