1985, 03-08 Permit App: 00004397 Garagea•
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AVID -COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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(Please return this original and your building plans to the Department of Building and Safety)
1 Owna'e Namd '(last) (first// (m)
Lemnmontllso only
4/Z --7//•o - 3 s o4 •�
N/MaWno
Re. IComm
Z✓
2 Project Address bd P Space
//4/is 1 2 .r 4/417 , p �920b
3 dtyl nIty •
o/CR74/C-
State
',151-J 4
Subdivision/Plat Name
A , 4., ,...
4 Assessor 1 No.Lot
-//6 �f/ -
51(L 3_-_e2/6 (~-
Block
, + , DEPARTMENT USE ONLY * w
5 Sic Cade -I'Zem Act..#
Zone / t Project No. ��
qrr 777
8 NMI. /
No. of Bull Inge
Sq. FL`
Depth -f-
Frontage Li{
7 Set Back -Fag
Hen
(L)S-1
3
IR)22 IPa
If
Oxuus Tract
Module No.
InitialsLn�,
`//y(e//vr'`Pej
18 Architect Firm Nyry ` I Street Address
Zip
(]y
State
Phone
Contact Person
Phone If different than Wove
( )
Cnt,n Firm Num
Street Aggress
ZIP
City
State
Phone
( )
°Detect Peron -
License No
Cl/�3-FAQ 8Q 6 /
Phoneli different than above
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8 Ownoi/Agent (if different than LT above)M'
0/06/86)
� LC/
Bust ase Address
9 Zp
qty
State
Phone
(
12 Review Required
Plan Check (YIN)
Other (YIN) ISEPA
xempt (Y/N/
Date
15 TypeWor ` 1:101/1:19
O Fire
❑ MH
0 Demo
Lfew
0 Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Workiv 6 262 X34
9E3V,
C
10 Applicant Name
Street
Address
11 Zip
ON
State
Phone
1
Conder
Street Address
Zip
Cly
State
Phone
1
Contact Person
Phone 11 different then above
1 )
Additional Information
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DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to (Intl as built approval
2 Indicate above or attach reasons for hold
1 nis Is nota Hermit
Application Type
(Standard unless
otherwise Indicated)
(indicated approvals required In either 'release" or 'release with conditions'
space prior to permit Issuance.)
o
❑
Fast Track
Early Start
Release
Release w/cond 1
Hold2
❑
Environmental Health El Commercial; I: Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
�—
APPLICATION #
Conditions/Comments'
❑
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone;
0 CU,yarlance, zone change; shoreline; 0 fence;
❑ Other
Conditions / Comments'
0
Engineers: 0 Commercial; ❑Residential; 0 Flood Plain;
N.811 Jefferson ❑ drainage 0 new access/approach; 0 fence;
0 road Improvements
Conditions/Comments'
❑
Utilities:
N.811 Jefferson
Conditions/ Comments'
0
Other:
❑
Plan Exam
Fire Prev.
Conditions/Comments-
onditions/Comments-0
0
Project Representative Telephone
Agencies Performing Special Inspection:
E
`0
2.
3
1 Indicate above or attach conditions relative to (Intl as built approval
2 Indicate above or attach reasons for hold
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