BOONE AVE H&S BUILDERS CORP-New Bldg /
,
, .
l
/
BUILDING PERMIT APPLiCATION WORKSHEET
PLEASE F'RIN7 AND CnMPLETE UNL~ 7HC)SF= PARTS 4F TNE FORM YUU UNOERSTAND
f-lease rCt~;- j, inis oriyinal an(i your ou,1ti-l►y t lans to ihe bepartment of Buildijig and Sa!ety)
~ OwnHr s Name (last'? ff s~ ~ (ml Clig~artmnnt Lfte (DniY
fbe 1 Cpmrn
~ f ~ n ' r. ~ ♦ ~ 4 1 < < , / _ ~
2 Pruqect Adclreay (not Ma,l rfy .4dd►ess) Q FiQad Name ~ 5pd~c~e Zip -
/ .
- - F-), - ~_t t
` ~ , (,`t` R 7~ ~ L~ : i ~tt r ..s_ • . ^ - . . . I .i.r - - - / 17
! UtyrCommunity Slate Sjbdlvision,IPlat Name
~ l ~ r ~ , ~ ;
4 Asaessor Pa►cel No W7 O~- ~ Lo1 l, ~ Bic~F
-Z 4 'Z ~ ~ C,/ / • * DEPAHTMENT USE ONLY w w t
l
~ tiSic Ccde Zo" qct. r Zone Project No
F p~l It No of 8uiidinpa Sq Ft ' Acre DePt^ FroMaQe
(
7$et gprlc-FrOnt (L)S-1 (R)S-2 Reer t-ensus Tract Module No Initie~k
f .
M
* 16 ArchlteCt Firm Name Street Addresa
`
zip _ f acy siate , awne ,
'N:
r.;' Z _
taLl permn Phone If ditferent than abo~e
(aontractor Flrm Name Streot Addresa
L. 1( Jv / ~'i z 1-c
2ip qty State Phone ;•1 ~ ~
ConRad Person , ~icenYa Phone {f Qifferent then above
:TOI /I ~ ~ . p : f ~-1- l - L Z 1 3 3
! ,1
g OwnerlAyent (if difierent tRan #1 above) Business Address
g 2ip City State Phone
( 1
12 Review ReQuired plan Cr,ecK (Y `N) plner (Y±N) + SEPA Exempt (Yf N) Oate
r .
15 Type Work Btiy MH ' New ' Replace Other
F~rr pemn AUd(Alter r. Move
14 Oemribe Work 1~ I
c~
~
I~ nt Name Street Addre~
10 APP
11 2ip aty ~ State • Phone t G~ ~
f ~ •
Lender . ~ . Slreet Addre9s /
Aiu,; . ~ ; ~.L • ~ ~ c. k i,...~~~ -~-C G l
Zip City State Phone
'c'a
Contac! Persor. Phone if drfterent tnan ebove
l 1
Addilkional I n oormatian
.
. ~
DEPARTMENT APPNOVALS
~
- Thi,~Ii:. i(t a Perrr;it
Application Type ;
a
(Standerd unless (Indic.ited epprovais rvq,llrud iri eitrie:, fvlease' .ip °ir.feasewith
; -
otherwise indicatad) space prior to pHrn►it issuance ) -
Fa9t Track
Eerly Start ~ I Release ~
- - - - - - : - - Reiease ; w 1 cond 1 Hold 2 .
~ - - - . - - - ~ - _"I i
- Environmental Health ~ Commerc:ial. Residential
W. 1101 COllege New Constructiun 61dg alteration laddition
Room 200 Additional str ucture -
APPLICATION M _
ConditionslComments: - - - - - - - -
- - - - - - - - - - - -
- - - - - - - ~ - -
' PIannlnq/Zoning. ~Commercial; ~ Cert of Exemption; _ Frontage;
- I
N. 721 Jefterson ~-i Setbacks; lot w/d: lot size; usel2one; - ~
Ci CU, vanance, zone change; snureline; tence;
_ Other _ , . - - - - -
Condition9/Comments: - - - • _ -
~ ~ - - - - -
~ En~lnesrs: ~ Commercial; Residential, 17 Flood Plain;
N. 811 Jefferson drainage - new accesslapproach; f; fence;
J
~ road improvements
Conditions/Comments: _ _ _ . . - -
U«liti.s: b. ~
N . 811 Jefferson
Conditions/Comments- Qt-- tD STf-MMIENT _ -U"vA►`eJ>
~ . Other: - - - - - . _ - - -
~ , Plan Exam _ I
Flre Prev. ~
~ I
Conditiona/Commants - . - - - - -
a - - - -
~
^ J Project Representative Telephone
~
a Agencies Performiny Special Inst.ection
U)
Y o - - _ . - - - - - - - -
' c
~ -
r`- E
~ E - -
o
c
ti _
3
1 Indfcats ebovs ar ettach condltlona relatlve to flnel es bullt spproval
2 Indlcate aDude or ettach reasons for hold