1985, 06-25 Permit App: 00006098 MHI a
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 (lot) (first) (m)
Only
ran,
i/AR A,V j ' ZaeXLA /.ANNA Ai �. / Kamm
2 Project Address riot Melling Addreesla Road Name Space Zlp
E 73zi 11h Ave Qrf2/2
3 City/ ii munity��
C�.J/2OJVa��
State
�g sr,
Subdivision/Plat Name
Mau ,N a�� A��
Wm,' Nb.
J Assessor rr ----A-04— 3
ott/ 17r18ok
Lo 1 6
Izoonne /
* * * DEPARTMENT USE ONLY * *
5 Sic Ota
Zone Act.
Project No. � p
_
celesq –G�
aVM�
og L�JC
6 Ewell a/\
\
Na. of Bug Inge
Sq. Ft./Acre
Oep1-Z -
--lt
e
Fr -7-
7 Set Back -Front I MS -1
(R)S-2
Rea
Census Tract
Module No.
Inn ,-s —
- lX
16 Architect Flrm Name 1 Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
1 1
Contactor Firm Name
Street Address
zip
Gty
I State
Phone
contact Person
Llmnse No.
Phone If different than above
( 1
8 Owner/Agent Of different than W above)
Bus' ees Address
9 Zip
City
State
Phone
12 Review Required
Plan Cbeck(YIN)
Oth r (YIN) IBE AExempt (VIN)
Dace
15 Type Work 0 Bldg
0 Fire
C/MH
❑ Demo
Cr New
0 Add/Alter
0 Replace
0 Move
D other
14 Describe Work
I v Mob /e l-loHe
10 Applicant Name
/7 u e 47.A f/• 1/ARM AA1
Street Address ((pp
%3r wesr /4t ,4w i9 %
11 Zlp
77o d Y
City
Ci. h •a Ne y
State
ta/4 s r/
Phone
( ) .,jt i/2 7
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
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
Conditions / Comments•
D Commercial;
O New Construction;
❑ Additional structure;
APPLICIQTION q
❑ Residential
❑ Bldg alteration/addition
U i:r iE%S
Release
Release
w/cond 1
Hold 2
C 1 ' 2;
SFrN
e Prev.
� �.
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage; /,%,,`j-�-
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 17use/zone: ‘-rq[t!/�t
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Ck-,-85 OH (8)
Conditions/Comments
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road Improvements
Conditions/Comments
PAPA-
❑ Flood Plain;
O fence,
0
Utilities:
N.811 Jefferson,
Conditions/Comments-
Other:
Pla
Firi
n Exam
e Prev.
Conditions/Comments
Protect Representative Telephone
Agencies Performing Special Inspection:
1
2
3.
1 Indkate above or attach condition relative to final as built approval
2 Indicate above or attach reasons for hold
r
1
53
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