HomeMy WebLinkAboutRS050825_APPLICATION FORMCOUNT '' OF OR;sNGEIPLANININIG ANC CEVELOPNIEN7 SERVICES Cf -
APPLICANT'S INFORMATION SHEET FOR A BUILDINGIGRADING PERMIT
Applicar., must legibly PRINT in a' of the known indicated inf rmation. PERMIT NUMBER:
EL'ILDING ACGn SS G= P:RQJ;CT IJ f f C�G1YJ�
N r,ner Street General Area
LEGAL DESCRIPTION C PROJECT SITE:{-
7raCt Black Lot
1Tmetes d bounds then ycu muss pr. ide a reGcrCed copy of:t;e Grant Dee' ,
= SSFSSOR'S PARCEL (.4,P) NO.
ry l~AREST CROSS STF E HTS:
OVVNER/BUSINESS NAVE:
OWNER'S PRESENT ADDRESS:
Nu rnber
\, i txi - rt_b 1
Gene ea of Cour,:, C;ty
SPECIAL PERMIT NUM-EHR:
Use PermitlSlte PlaruVarar.se
ZONE:
Zip Phone No,
PROPOSED USE OF STRUCTURE.- This must be c'eariy spelled out in detail as to exactly what is the intended
use. The terms "OFFICE" or "COMMERCIAL BUILDING" are NOT sufficient to determine if the proposed use
meets the Zoning District Regulations, Occupancy Group, or if the TYPE OF CONSTRUCTION will permit the
proposed use. BE SPECI=IC:
STRUCTURE SIZE SQUARE FEET: �� [ 1� t ,- =fit + -- / - ►,. ��
Tptal ist loor 2nd Floor 3rd Flcor
GARAGE SIZE SQUARE FEET:_ 1 "Ic . ?t -(. -1 i 'A SIZE SQUARE FEE C>f-Ck:5-s �L-,(u
(other)
CONTRACTOR:
Name License Number Ctassiricatien
Number Street A,, 0aiC;ty Phone No.
Warors Camp Carrier poll! •y dumber Gate of Expiration
ARCHITECT: ',I`t�� -i / / `d ' �. t k7 1 `.� 44• 1r��
_ Name • Uc. No, Number Street Area/city Phone too
ENGINEER: �� . Lq � );,A l r .c ; . . / `1 k 1 l`{ - 3—
?+ame it'i.ul`Y s L:C_Nc. NumherStreet ArealC;ty PhoneNe.
CONTACT PERSON: AFFILIATION::
F.A_X#_ _iIL1 1,-Li1 t$1 ' PHONE #
APPLICABLE TO GRADING ONLY
SOIL ENGR: I I I I
4sme L:c. Nc. Num'cer Street ArewCity Phone No.
ENGR. GEOL: I - I' I 1
Name Lic. No. Number Street AreaiCify Phone No.
CALIOSHA REQUIREMENTS/CHECK APPLICABLE BOX: ❑ 1 am the owner -builder and exempt from state
permit requirements/❑ I =_ckncwledge that I must sutmit proof of issuance of CAVOSHA permit for the project,'
7 The project does not r_quire a CALrOSHA permit. based upon the criteria on the reverse side of this sheet.
I herewy Certify that t0 the best of -ny kncwfedge the information scpt~fied or, this inkrmaticn sheet is true and correc!.
SIGNATURE: CJl } i L�A.TE I -5 635
P-Cperty N -er or AuthOnZed .Agent
SEE OTPER SIDE