1984, 10-19 Permit App: 00002939 MH CoverN
BUILDING PERMIT APPLICOo WORKSHEET THE FORM YOU OUNDERSTAND
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name / (last)
&V/
(first) (m)
,E✓L T -
2 Project Address (net Mailing Address) a- Road Name
V/5 State
3 CltylCommunIty
5, o/ Nts
*
Space
pepartment 9watly
Rte. ✓ Comm
Zip
er'/ �7
!�J p
4 Assessor Parcel No. ,
0��� e)&676
5 Sic Code
6 Dwell #
7 Set Bads -Front
Zone Act.
Lot
6
Su /Plat Name •
Very t e ,e) M tit cjce1
Block L/
* * * DEPARTMENT USE ONLY * * *
No. of Buildiinngs
.G/
Zone
(L S-1 1(R)S-2 'Rear
16 Architect Firm Neme
1417710 --DO/V"///
��y
P zi
o
/3/M
7/771/29 -fill)
Contractor Firm Name
Sq. Ft./Acre
Project No.
5--7g3C
Depth
Census Tract 1
Module No.
Zip
I Clty
*
Contact Person
l License No.
8 Owner/Agent (if different than #1 above)
9 Zip I City
12 Review Required
State
I State
I State
IPlan Check (YIN) 1Other(Y/N)
15 Type Work
❑ Bldg
❑ Fire
I❑ MH
❑ Demo
D New
Add/Alter
14 Descry Work e V ` t C) vet ^ ; J ,/_ 1 /e- keim e-
ltc�.>�
IW
f!? 9 4
10 Applicant Name
11 Zip
Lender
I City
State
Frontage
Initials
1 Street Address .
) rhe -‘2 ,C
Phone
(
Phone If different than above d
IStreet Address
Phone
Phone If different than above
( )
IBusiness Address
I Phone
O
ISEPA Exempt (Y/N) I Date
❑ Replace
❑ Move
IEr ---Other
Street Address
I Phone
( )
IStreet Address
Zip
Contact Person
Additional Information
I City
I State
Phone
( )
Phone if different than above
( )
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application
This is not a Permit
•
Type
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
•
—
Early Start
.
Release
Release w/cond 1 Hold 2
0
Environmental Health ❑ Commercial; ❑ 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; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments.
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
0 road improvements
Conditions /Comments*
Utilities:
N. 811 Jefferson
Conditions/ Comments•
•
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments•
TJ
Project Representative Telephone
c
O
Agencies Performing Special Inspection:
1
Iii
E
0
2
c
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold