1984, 09-19 Permit App: 00002369 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)
^ (first) I. (m) Dsperiment Only
1 Owner's Name (la ft)
-
�Ill\ V
D
I
Y Rs. - Comm
2 Project Address (not Mailing Address) Road Name Space Zip
1.‘,..igga27
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3 City/Community
ck U' VCIACtt ct S
State
1-11C1•
Subdivision/Plat me
L� B( ' ' ecv–key-
i(e
1 Parcel No.
L.
c6'S F _ 0 20H .
cdCadeV `' L
Lot
S I),
Block
7
a
a t * DEPARTMENT USE ONLY * * *
5 Sicic
Zone Act.*
Zone ��\ -
Project No. casco,/
6 Dwell*
1
No. of Buildings
(
Sq. Ft./Acreh
(
l Dept1S1
Frontage
)
J) 1–
r 7 Set Back -Front I MS -1
r
II
(R)S-2 I Rear
Census Tract I Module No.
initials
16 Architect Firm/lame Street Address
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•Zip
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City
SPN (r«tee
State
C..Ju_
Phone
(-5-10%) 922— rsoS
Contact Person iThPhone
uv� vyCe
If different than above
( I
Contractor Firm Name
S Ct 1/"\e_
Street Address
Zip
City
I State
Phone
( I
Contact Person
License No.
Phone If different than above
( I
8 Owner/Agent (If different than *1 above)
Busi ess Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N) ''Other
(YIN) ' SEPA Exempt (V/N)
Date
15 Type Work 0 Bldg
❑Fire
%'�–MH
0 Demo
New
0 Add/Alter
,—Replace
0 Move
0 Other
14 Describe Work
(�'t.o6c(e Ine tj,e_t¢ce ec 2 x &
10 Applicant NameStreet
lin 5a(AA e us arrL(--ecI.
Address
11 Zip
City
State
Phone
( )
Lender M -
4ltnteke 0 t0V
Street Address
Zip
City
State
Phone
( ) LI56– ti36
Contact Person a p
Phone if different than above
Additional Information
f
*
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
O Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
ail
APPLICATION #
Conditions/Comments.
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; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments
Utilities:
N. 811 Jefferson
Conditions/Comments
El
Other:
Plan Exam
Fire Prev.
Conditions/Comments
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach condltlons relative to final as built approval
2 Indicate above or attach reasons for hold
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