HomeMy WebLinkAboutBLD1987-00364 • N E
I. LOCATION: prop.aphic name S kr SIDE OV ROAD FEET
AO
S W FROM INTERSECTION OF ROAD AND git (,ken eSS dROAD
other specific location or landmark: q
LEGAL DESCRIPTION: Subdivision
�ParL�l t*- Lot Block
17 I ao
Tax mber Y.Section Section Township Range
II.TYPE AND COST OF BUILDING
TYPE F IMPROVEMENT BUILDING TYPE PUBLIC WORKS APPROVAL
building 0 Single Family
❑Addition 0 Multi-Family number of units Road Access Permit No.
❑Alteration
0 Hotel,Motel, Dormitory Utility Permit No.
0 Repair,replacement number of units
W 0 Wrecking 0 Mobile Home Emergency Services No.
❑Moving(relocation) Ql�Other—Specify Street Width A'
❑
lo
Foundation only / /�
narrl.� e B:
U Additional Permits Required:
OWNERSHIP
Private(individual,corporation,
nonprofit institution,etc.)
❑Public(Federal,State or local gov't.) USG OCCUPANCY GROUP: �'/
COST (Omit cents) Nonresidential- Describe in detail proposed use of buildings,e.g.,food
• Cost of improvement 4 processing plant,machine shop,laundry building at hospital,elementary
To be installed but not included school,secondary school,college,parochial school,parking garage for
in the above cost department store,rental office building,office building at industrial plant.
a. Electrical If use of
} -
f existing building is being changed,enter proposed use.
b. Plumbing X 4a-LI [ iQ tt' S 4 8 L f�
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c. Heating,air conditioning
`�1`I F mil
d. Other(elevator,etc.)
• TOTAL COST OF IMPROVEMENT S
III.SELECTED CHARACTERISTICS OF BUILDING -
DIMENSIONS
PRINCIPAL TYPE OF FRAME TYPE OF SEWAGE DISPOSAL t •Number of Stories
i O Masonry(wall bearing) ❑Public or Private eX(S I •Total square feet of floor area,
`,GL \Wood Frame RIndividual(tseptic tank etc.) all floors,based on exterior
- b dimensions
/0Structural steel
TYPE OF WATER SUPPLY •Total land area,sq.fL
❑Reinforced concrete
0 Public or private company ;
Other-Specify NUMBER OF OFF-STREET
Individ (well, stem) PARKING SPACES •
Enclosed C2N •
PRINCIPAL TYPE OF HEATING FUEL TYPE OF FIREPLACE Outdoors
O Gas
Oil RESIDENTIAL BUILDINGS ONLY
Number of bedrooms
❑Electricity TYPE OF ME NICAL
Coa Number of ull
Other-Specify bathroo Partial
IV. IDENTIFICATION _
Name Mailing Address-Number,street,city and State ZIP code Tel.No.
•
1. QImfiOrr rt,SOh p(i 1 0) .5 , q 9' t7U1 _ '.
Owner i.
2.
Contractor (\l
ry�� State License No. _3 �t? I
� , f,, k a
3.
Architect i
The owner of this building and the undersigned agree to conform to all applicable laws.
Address (//�'� �1 )/� pp�yy�ion te n I
Signet of aPPI� 4-3 i9 & l e CJ� L
P NING AREA FIRE DISTRICT SCHOOL DISTRICT WATER DISTRICT
APPROVEDra G APPROVED 3Y APPROVED BY
JEFFERsou HEALTH DEptiSHOVELINE DEPT. PLANNING DEFT.
APPROVED BY: PERMIT FEE ISSUE DATE RECE1PT NUMBER
T,
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