1985, 04-16 Permit App: 00004962 Remodel'-- -(tV3/
BUILDING PERMPPAPJ LICATION 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)
1ner'sName " Oast) p Iml
ppgdme nl t8e ly
2 ' .jec1 Addrss (not Mailing Address) a' RoadName Space Zip
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,
3 City/Community
SPOIL J�
State
w� 4 .
Su III IPIat Nint
x/,(.21- Q 15 T
O 2 T / _
4 Assessor 15�r3 2 —03040
1,
Lot
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Bek 4 •I t f. f DEPARTMENT USE ONLY * * *
5 SIEC Code
Zone AELY
Zone
A'SProject No. ��
1/9
5 OnelU
No. of augdings
Sq. F
Depth
Frontage
7M1.377
14.0Nem*
(L)S1
0115-2
Rear
Census Tract
Module No.
�or.
IVI
16 keelleeott Firm Nem*
Street Address
Zip
Cly
State
Phone
1 1
Cantel Person
Phone If different then above
1 I
CNr or Flint Name �y
1W\ ST I Y\Sbf\ gi*OWST,
Street Address
t t'3 c) Q. JE,Ai
;970 7
City
SPOLL ACK
State
w✓J.
Phone
(SCr/ l qii -?a 5-7
Contact
License Na.
..---t tMszc ZzaK
Phone If different than bore
( ) S-att„ti.7.._.
8 Owner/Agent Of different than el above)
Bind ess Address
9 Zip
City
State
Phone
12 Review Required
Pi n Check 1Y/ N)
Other (YIN( �6EPA Exempt (YIN)
Date
15 Type Work ❑ Bldg
❑ Fire
0 MH
0 Demo
0 New
D1�dd/Alter
❑ Replace
0 Move
❑ Other
14 pecrlbtWak
tk-bN 111J>.1AAA.e .:. tivt-44,V c LGV ‘0 /l�n%���e
10 Applicant Name
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
( 7
Contact Person
Phone If different than above
( )
Additlanal information
TT
et 3906
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
DEPARTMENThPROVALS
This is nota Permit
(Indicated approvals required In either "release' or'release with conditions"
space prior to permit Issuance.)
0
Environmental Health
W. 1101 College
Room 200
❑ Commercial; ❑ Residential
❑ New Construction; 0 Bldg alteration/addition
❑ Additional structure;
APPLICATION it
Conditions/Comments: eigo:aftir
Release
Release
w/cond 1
Hold 2
4 fp
Planning/Zoning:
N. 721 Jefferson
❑ Commercial;
0 Cert. of Exemption; 0 Frontage;
ID Setbacks; 0 lot w/d; ❑lot elze; ❑use/zone I.
O CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions / Comments*
0
Engineers:
N.811 Jefferson
O Commercial; 0 Residential; 0 Flood Plain;
❑ drainage 0 new access/approach; ❑fence;
❑ road Improvements
Conditions/Comments
1)111111..:
N. 811 Jefferson
Conditions/Comments•
Other:
0 Plan Exam
Fire Prev.
Conditions/ Comments.
Project Representative Telephone
Agencies Performing Special Inspection:
1
2.
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold