1984, 06-18 Permit App: 00000706 MHBUILDING 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
Own ' Name
(last)
r
(fir
m)
Department Use Only
fes. Comm
2
Proji6ct Address (not Mailing Address) or Rmd Na a
Space Zip
3 GtylCommunity
4 Assessor Parcel No.
r
7
O
StateSubdlv�onlPlat ��
f /'
Lot Block
♦ * DEPARTMENT USE ONLY
Zone Act. #
Zone
Project No. �O
ro
PD
No. of Buildings
Sq. Ft./ Acre
Depth
�a /� I
!N•I'I
Frontage
�t7
t
(L)S-1
(R)S-2 c -fRear
Census Tract
Module No.
Initials
Jomm
Name
Street Address
City
State
Phone
Contact Person
Phone if different than above
Contractor Firm Name
Street Address
Zip
city
State
Phone
Contact Person
License No.
Phone if different than above
8
Owner/ Agent (if different than #1 above)
Business Address
9
Zip
City
State
Phone
12
Review Required
Plan Check (YIN)
Other (YIN)
SEPA
Exempt (YIN)
Date
15
Type Work
❑ Bldg
❑ Fire
/v,�MH
❑ Demo
❑ New
Add
11/Alter
EJReplace
❑ Move
❑r
14
Describe Work
rYto$ Kf,'- Pg9m
L:�o K — 0 to
10
Applicant Name
Street Address "
11
Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
l )
Additional Information
Q
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2. Indicate above or attach reasons for hold
I nls Is not a rermlt-
Application Type
(Standard unless
(Indicated approvals required in either "release" or "_release with conditions"
otherwise indicated)
space prior to permit issuance.)
❑
Fast Track
Early Start .. ,
Release
Release w/cond 1 Hold 2
Environmental -Health
: "' Commercial; O Residential
W. 1101 College
❑ New Construction; ❑ Bldg alteration/addition
Room 200,
❑ Additional structure;
APPLICATION #
Conditions/ Comments:
❑'
Planning/Zoning:
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson .
❑ •Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
,..
❑ Other
Conditions/ Comments:
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;
Gig
N.811 Jefferson
❑ drainage ❑ new-access/approach; ❑ fence;
❑ road improvements
'r
Conditions/ Comments:
❑
Utilities:.
N. 811 Jefferson
Conditions/ Comments:
❑
Other:. .
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:-
nspection:O
0
'
ca
E
2.
0
_
3
1 Indicate above or attach conditions relative to final as built approval
2. Indicate above or attach reasons for hold
�s
Y-