1985, 03-19 Permit App: 00004531 Pool`syr r
4-4 � J BUILDING PERMIT APPLJCATION 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 ownr's Nam 9aet) firet) (m)
Opriment Only
TA/1411 a0 3
e. .i Comm
_
2 Project Address (not Mailing Addresscr-e Zip
Ave X99206
)E y71
3 Gylc�vrnunly/152'/
-S�o R/td.r/G
State
w�/
SVbdl�eOnlPletNeme
A/ £S'hMs No 7
4 AM tO(� iy�yo.
0i,CT' /_ 050
r %
A
Lot
17_/
Block
* * * DEPARTMENT USE ONLY * *
5 SIoCode
Zone M. •
Zone sFe Project No.
6 Dwell II
No. of Bull Inge
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Fant
--------
0.15-1
RS -2
Rear
Census Tract
Module No.
Initial• s
//
16 NMltect Firm Home I` I Street Address
Zip
City
State
Phone
( )
Contact person
Phone 11 di(Ietent than above
( )
Contractor Firm Nam.
WEsreg ,</ s/;oToQETE coteP
Street Address
g 12706, /Ve2R
zip
992/6
CIy
stox..AwE
Slate
1..,, v✓
Phone
(SOI) 9''2.S-- %V
C dx1 Pomo
4E0 cvADOE//
License No.
011.JEft/(a9/.P
Phone If different than above
( )
�1'D
8 Ownr/Agent(If different than 0l above) WLSTLs; / 12/ t
Bus) ess Address
9 Zip
City
State
Phone
12 Review Rpulred
Plan check(Y(N)
Oth r MN) 'SE AExempl (YIN)
qts
15 TypeWork ❑ Bldg
❑ Fire
0 MH
0 Demo
New
❑ Add/Alter
❑ Replace
❑ Move
[f Other
14 be Work
/GK3z d/ San/MN/nfa Pool 50oFf
10 Applicant Name
Street Address
11 ZIP
City
State
phone
(
Lender
Street Address
Zip
Cly
State
Phone
( )
Contact Person
Phone If different than above
Additional Information
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required In either "release or 'release with conditions°
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
O Residential
❑ Bldg alteration /addition
APPLICATION #
a: 4
Release
Release
w/cond 1
Hold 2
Conditions / Comments'
0
Planning/Zoning: 0 Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 uselzono;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments-
0
Engineers:
onditions/Comments-
Engineers: 0 Commercial; 0 Residential;
14.811 Jefferson 0 drainage 0 new access/approach;
O road Improvements
Conditions / Com ments•
❑ Flood Plain;
❑ fence;
Utilities:
N.811 Jefferson
Conditions / Comments'
Other:
0
Plan Exam
Fire Prev.
Cond Mons•
Protect Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
mat,tia.%u
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