1984, 07-23 Permit App: 0001362 Mobile Homej�
1.
PLEAS
BUILDING PERMIT APPLICATION WORKSHEET
E PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
{Please return this original' and your buiildirig pians to the Deparimenii of Building and Safety)
t
3 City
S. - - unity
a S ir
-Al ar A .
State Sutklivisionii Plat Nolte
1 V4 lariL TrAi re" :5al
Pr Sr
4 Assoc Pun* Mt
it
Bleck
I
e
* * * DEPARTMENT USE ONLY * * *
.iti: 2 a 100 01
5 S1C • I.
Mae Owl 0
Zone 11672_ nil pe Projed NO
6 Dwell a
ii
NO. Off l'
ul Id ings
L
Sq Fl (Acre
,
Depthli
Frentilla
a. I
us)
7 Sel Beek-Fronf
ti
0-)8-1 (11)S-2 f
Reillit't i
Carious Tract
Module NO.
thillitala
2
349. 1
On
16 Archrtmt Firm Name
Street Addreti-t;
Zip
! City
$.1ale
i )
ech1act PECSOfti
Phone if dilleren1 than E1130Y -
1
alairtictOr Firm, Name
Streat
Address
i 1
tY
Slate
Phone
(
)
Contact Person
Lamle NO.
Mee
(
I r different lbw above
)
8 Owlet II Agenr, I:if different than
et above)
Business
Address
9 Zip
i City Stale
' Phactie
: fal 91
12 Reviler* Required
Plan CheCkfrilti * I
•
SEPA Execript (V/ -
ii,
Dete
------
15 Type Woik Bldg
Fire
MH
Demo
T New
Add Al ter
'-' Replace
Move
_ Other
.17
i_. is
14 Davi be Wark_res. . " 01 a .i.
i
10 Amami Woe
Won 4
P
wit ar ragest : 0 er has
Ziede roor s
11 Zip
99Pa/6
Lender
z$p
COriteCt Person
Add I tional I nf armor ice
Street Address
.7tee e
Slate
erireAdoects
State
Phone
k257) 57eq 44 7140,5 --
Street Address
Phone
Phone 14 di fferen11 han stickle
or
Applltation Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
Environmental Health
W.. 1101 College
Room 200
Conti i titins IComments:
DEPARTMENT APPROVALS
This is.221 a Permit
(Indicated approvals requ I red In either °release' or release with Gond l iio ns
space prior to permit issuance )
Commercial;
El New Construction:
❑ Addition I structure;
APPLICATION I
❑ Residential
l
El Bldg alteration ! addition
r
Release
- Release
ye l Gond 1
Hold 2
0 Cert of Exemptions
IT lot w i t .
L Frontage,
Rot alai. E use i" zona.
-
-
1
Planning/Zoning: 0 Commercials
fel.. 721 Jefferson 0 Setbacks;
CU F variance, zone change; shoreli ne,
®'
Other
Ca d ht Ions Comments-
El
Co ments
El fence;
Engineers: 'pCommercial; 0 Residential; 0 Flood Plain;
N 811 Jefferson CI drainage 0 new access !approach; 0 len ;
0 road Improvements
Coriditionst Comments
Utilities:
N 8111 Jefferson
Gonditionsitomments
■
Other:
0.
e
c
Plan Exam
C
■ lr• Prays
Condit lan!Com ren tx
P fo ra fo
Project Representative _.Te .he
Agencies Performing Special II res pect I ons
1
1 Indicateabove of attach conditions relative to final as built approval
2 Indicate above or attach reasons far bold
0 Cert of Exemptions
IT lot w i t .
L Frontage,
Rot alai. E use i" zona.
-
-
1
El fence;
Engineers: 'pCommercial; 0 Residential; 0 Flood Plain;
N 811 Jefferson CI drainage 0 new access !approach; 0 len ;
0 road Improvements
Coriditionst Comments
Utilities:
N 8111 Jefferson
Gonditionsitomments
■
Other:
0.
e
c
Plan Exam
C
■ lr• Prays
Condit lan!Com ren tx
P fo ra fo
Project Representative _.Te .he
Agencies Performing Special II res pect I ons
1
1 Indicateabove of attach conditions relative to final as built approval
2 Indicate above or attach reasons far bold
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eget
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