1984, 10-22 Permit App: 00002963 Sunroom •
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)
ts00 Past) /VIIr (ml I(�pytrtrnt U(a Only
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Address(not Mailing Address)cr Road Name Space Zip
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3 Oty/Community State Subdivision/Plat Name
1 S [-/� A, 0 1�tJ/4 KoIca ybto TcwF�SiTc tU
1 Assessor No. I lot a Block
2 X422 _ 5 t}�3 /,1n '!I tt e ♦ e DEPARTMENT USE ONLY • • *
5 Sic Code Zone Act.I l .l Zone Project No.
At, Sur)
6 Dwell I No.of Buildings So Ft/Acre Depth Frontage
I
7 Set Back•Frent I IL)S-1 (P15.2 !Rear Census Tract Module No. "tial ,....)„,
* 16 Architect Firm Name I Street Address •
Zip Oty State Phone
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Contact Poem Phps If different than above
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/ Contractor Firm wry) Street Address
C/ s�O <Did g77Z7 Inst( c
Zip Oty State Phone
e c �o�L A. (say ) rilin,
Contact Person
///��// Licence No. �/ T // Pitons II different than above
8 Owner/Agent Of different than al above) Business Address
9 Zip City State Phone
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12 Review Required Plan Check n/N) Other IVIN) SERA Exempt(VIN) Date
{ la? \IC. —
15 Type Work ',/ Bldg MM " New ' Replace -- Other
_. Fire 7 Demo /Add/Alter 7 Move
11 Describe Work
O<.cN 12c0tn. AOC)IT.ont 63--4) Jr (1 Z >( 13
10 Applicant Name Street Address
11 Zip City Stale Phone
I 1
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Lender Street Address •
Zip City State Phone
I 1
Contact Person Phone If different than above
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Additional Information
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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.)
Fast Track
Ll Early Start Release
ROMS w/cond 1 Hold 2
r,
sAs Environmental Health C Commercial; Residential /t_/ a
W.1101 College ❑ New Construction; Bldg alteration/addition
Room 200 0 Additional structure;
APPLICATION I /+-/4Try 7
Conditions/Comments:
Planning/Zoning: 0 Commercial; 0 Cert.of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; ❑ lot wld; 0 lot size; 0 use/zone;
❑ CU,variance,zone change;shoreline; 0 fence;
O Other
Conditions!Comments:
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage ^ new access/approach; 0 fence:
C road improvements
Conditions/Comments:
o Utilities:
N.811 Jefferson
Conditions/Comments: —
Other:
Plan Exam
Fire Prey.
Conditions/Comments:
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P
C❑
• Project Representative Telephone
Agencies Performing Special Inspection:
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E26- 2
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9.
t Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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