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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