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Planning Application No. Building Permit No. <br />ORM <br />' CITY OF PLEASAN'I'ON <br />Development and Building Application Information: Impervious Surface Form <br />Complete at both the develo/pment application stage, and at the building application stage for all projects. <br />Date of Application: 3l ~ S/ 0 ~ <br />Type of application: ^ parceUtentative/vesting/tract ma ~ site development review ^ building permit <br />Project Location or Address: Jc' `I $0 ~" 5 R ~ $ SuK ~~ 61 vd ~. /~~~ra S 4'•/"1b H , CA y`f f b G <br />Applicant shall submit a map clearly indicating the location of the project. <br />ParceUTract No.: Lot No.: APN # ~ y l~ ~ ~ - ~ " `~ q ~ ~- y - Z - ~ <br />Project Name (if applicable) J ~ ~ o ~ 1 Yb ~t SSA o n ~ P ~h2 q <br />Type of Project: <br />,~" Commercial ^ Industrial ^ Residential ^ Public Agency <br />Property Owner's Name: N1~ Khv~), i'o"h~G{ S/~„/~(~u~, O~i// Phone # $(~. `76. ~(S(o3 <br />Applicant's Name: t GEC Kit/A ~bft <br />.$~ Owner ^ Contractor 0 Engineer/Architect ^ Developer <br />Applicant's Address: 3 `LLD ~ s fti~-( $ f F/~wr o ~~ C A g ~f S 3~ <br />Applicant's Phone: ~ (° • 676. ~r63 Fax: S7t~•~y/..~5-Z~ Email: hK9v~5®p~~'a~a~til ~/1.Co~.., <br />Total Lot (or ParceUTract) Area in sq.ft ~ 3, oo `~ <br />Type of Impervious Surface Pre-Project (Existing) Estimated (at planning New Project <br />(Areas that rainwater cannot Impervious Areas stage) Proposed New Impervious Areas <br />* <br />penetrate, such as asphalt, in sq.ft. Imperious Areas in sq. ft. <br />concrete, etc. ins .ft. <br />Building(s) Footprint Z 2~~ 4 D p <br />~ ~ <br />Includin Attached Gara e ~ ~ <br />Driveway(s), Patio(s), Parking <br />y ~ D <br />~ G p a <br />3 ~ <br />Lots , Im ervious Deckin s / <br />Detached Garage(s), Carport(s), <br />~ <br />I Z ~ <br />Shed(s), Other Misc. Structures <br />Off-lot Impervious Surface N/A <br />(Streets, Sidewalks) <br />Total Impervious Surface in ~/ 7 o b y ff~ ~{ Z-D <br />S uare Feet <br />* Completed when initial construction plan submitted <br />I declare under penalty of perjury, that to the best of my knowledge, the square footage presented herein is <br />accurate and complete. Incorrect impervious area calculations may delay your project application(s) and/or <br />permit(s). <br /> <br />ature o f/Appli <br />Date <br />Staff Review Board Required: <br />^ Yes ^ No Planner's initial <br />Y:\Stormwater-C3-permii\Final-FormsWPDES CoP Form A.doc Revised Date: November 1Q, 2004 <br />