1985, 05-15 Permit App: 00004988 MH-c a
r
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)
1 Owner's Name (first) (m) meat Only
1
CD/l /yps Q�1-y) F� . �� V
Collins
Comm
2 Prgea Address (not Mailing Address) or Road Name I Space` Zip
N I I1�1 Bes3j a. .CligDI7,
3 City/Community
l/�
State
l
//��lr
Subdivision/Plat Name 1iucten 11h U5t'cn1'1 /Ll4-i
4 Assessor
Parcel No.
I c;5 ) — Dgc,
Lot
Block
t t * DEPARTMENT USE ONLY * * *
1 5 Sic Code
Zone Act. 4
Zone' (
Cra
Project No.
C 0
ll.J/
6 Daella
No. of Buildings
Sq Ft./Acre
Depth
1
FrontageQQag�
Com/ •
7 Sat Bppc-Front ,
(L)S-1
(RIS-2br
Rear
Census Tract
Module No.
Initials
2d`
ii
16 Architect Firm Name I Street Address '
Zip
Clty
State
Phone
Conte Per
Phone if different than above
( )
Contractor Firm Name
al(Ite& 000-ire( 0fers
Street
C
Address
i (oa(/ 72". a.e.„14...), .
Zip
9c 1(P
City
Slpokt)tvle.
State
Uk:. C::
Phone .
( ) `r a-)Da0
Contact Person
rn I Ke, S{ /YK
License No.
Phone if different than above
I )
8 Owner/Agent (If different than 41 above)
Business
Address
9 Zip
City
State
Phone
( I
12 Review Required
Plan
Check (Y/N)
Other(Y/N)
(SERA
Exempt(Y/N)
Date
N -E;
15 Type Work 0
0
Bldg
Fire
77 MH
/❑ Demo
❑ New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
M 11-4s
SP ger S. : (z:r3cn,2-o.ti-2
(wx��.
10 Applicant Name �.
')CJYA€ (iS
akve_.
Street
Address
C aiRD6 toeIIcs/ecl -tI<
11 Zip
9 D 97
Clty_-(S
c__�
brc?klvr-05
n
State
LOCI, S CL—
Phone Got,Tk 7L47 -7/I1
( ) iigniii ci D L2 c1 / l
,
_.--
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information'REFl
a•- te-Dna) qc5
-tt+E ( gC I e 4 -6C
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health • ❑/commercial; 0 Residential
W. 1101 College ' New Construction; 0 Bldg alteration/addition
Room 200 ' ' 0 Additional structure;(5---6:12
'
D
APPLICATION p 3 Oc2 e2"5 --
Conditions/ Comments•
5Conditions)Comments n/2/kv7/U'DLC i11fi2/T./iI.-sj. 71/LE ✓0liL/,C--
Release
Release
w/cond 1
Hold 2
iza
_.,LL.ril
El
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments'
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson ❑ drainage 0 new access/approach;
❑ \road Improvements
Conditions / Comments•
❑ Flood Plain;
O fence;
Utilities:
N.811 Jefferson
Conditions/Comments
El
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 Indicate above or attach reasons for hold
e
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