1985, 09-27 Permit App: 00007724 Residence 4
.
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 Owner's Name past) (first) (m) Departmen Only
3' �t / / e. Fla. Comm
2 Project Address(not magRg Address)or Road Name Space Zip
/fes/ '34 ' 6' _
3 City/Community State , SZ,/IrLne4n/ e,( e s2."./�•
4 Assessor
Parcel 5z( --15-6
� Lot Btoc
,t ,t * DEPARTMENT USE ONLY * ,t
5 Sic Code Zone Act.# ZoneProject No. j 7 -h
6 Dwell N No.of Buildings Sq.Ft./Acre Depth Frontage
1 t
7 Set Back-Front I(L)S-1 (R)S-2 'Rear
Census Tract Module No. Initials
* 16 Architect Firm Name Street Address *
7W� , s/6A/
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Addr s
Zip City State Phone
Contact iLicense /�/� Phone If different than above
;e1 li.
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace 0 Other
❑ Fire ❑ Demo 0 Add/Alter ❑ Move
14 Describe Work
10 Applica "/& ai�_�' we . Street Address
11 Zip City�, State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
Ca.C20 v5-»x'
1 e50 i 2cth ut
1 5 . 7-- 40Le c 41a—
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.)
0 Fast Trackr
0 Early Start Release
Release w/cond 1 Hold 2
r__,
, Environmental Health ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure; 7
APPL ATION# ,r:/U4J �L- Q
Conditions/Comments: may/ j'�'o ,
CI 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:
f1J� '
❑ Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain; lie/
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments: /ice//t' _ V
0 Utilities:
N.811 Jefferson
Conditions/Comments:
El
Other:
•
❑ Plan Exam
Fire Prey.
Conditions/Comments:
d
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Project Representative Telephone
ca. Agencies Performing Special Inspection:
Y O
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H E 2.
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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