1985, 03-07 Permit App: 00004396 MH 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 (last) (first) (m) Department Use Only
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2 Project Address(not Mailing Address)or Road NameSpace Zip
E. ..�0 0 c2 , A1,/z ?9 616
3 City/Community State Subdivision/Plat Name
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4 Assessor Pargrel No. LotBlock
,Vc 7 J—,1.7— >� ri /' 45 * * * DEPARTMENT USE ONLY * *
f � '37-h'8a.�
5 Sic Code 7Ane Act. g4 Zones , / Project No. -1316
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
/17 / 3
7 Set Back-Front (4)S-1 JQf /D'J2S'
(R)S-2 Rear Census Tract Module No. Initials
25 ' 197irc5
* 16 Architect Firm Name I Street Address
Zip City State fl Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
Zip City I 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(Y/N) Other(Y/N) SEPA Exempt(YIN) Date
15 Type Work ❑ Bldg j53: MH ❑ New ❑ Replace ❑ Other
/71C'Ye. and C--)71/01-4.-1 e ❑ Fire ❑ Demo 0 Add/Alter X. Move
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14 Describe Work
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10 Applicant Name Street Address
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11 Zip Cityeti State Phone
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Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
DEPARTMENT APPROVALS
This is nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Trackr
❑ Early Start Release
Release w/cond 1 Hold 2
J `
Environmental Health ❑ Commercial; CI
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition 3.?-$.S
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Com ts: J'�_. fie . I ( / . - . i
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage; "?-85
N.721 Jefferson CISetbacks; CIlot w/d; CI lot size; 0 use/zone; i �:
❑ CU,variance,zone change;shoreline; ❑ fence;
❑ Otherr
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Conditions/Comments: - kisOK. -bp mamma& • .e) - „� , 4 p ,
tarTL� !.6..W, 4t2z 1111t0 ... WT” .
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Engineers: C7 Commercial; ❑ Residential; Cl Flood Plain; pj� ,
N.811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
CIrp.d ' provemen r- c
�T �� �Conditios/Co ts: � �� i�� � _ ��� .�n � �
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Utilities:Jefferson
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Conditions/Comments: -
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Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
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Project Representative Telephone
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a Agencies Performing Special Inspection:
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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Additional Information