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STATEOF CALIFORNIA .Rl LSIN CS 1RANSpORTATION AND HOLMSINGAGENCV Amnld SrhwanPnArnar fnvP
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
MOBILEHOME OR RECREATIONAL VEHICLE PARK
GOVERNMENT AGENCY APPROVAL FORM
NORTHERN AREA OFFICE SOUTHERN AREA OFFICE
9342 Tech Center Drive Suite 550 3737 Main Street, Ste 400
Sacramento, CA 95826 Riverside, CA 92501
(916) 255-2501 (951) 782-4420
This form is for use by applicants for a Department of Housing and Community Development Permit to
Construct a mobilehome park, recreational vehide park or additionsrmprovements as noted below.
The applicant listed below is applying to the Department of Housing & Community Development (HCD) to
construct a project which is located within _ _ _ '6"44c_ (city 4 r cou HCD is
the enforcement and permit issuing agency for construction within mobilehome/recreational vehicle parks
at this location. Prior to issuing any construction permits HCD must be assured that the project has
received all required government approvals. Accordingly, HCD has instructed the applicant to obtain
signatures from the agencies which are checked below. Comments and conditions of approval may be
attached.
If your agency wishes to be contacted prior to final inspection approval please indicate by
checking so under your printed name. For agencies requesting final review, this form will be re-
circulated prior to final inspection for signature confirming that the project is in compliance.
Project name:
Project street address:
Assessor's Parcel #:
Describe work to
be done:
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Applicant/owner. Elf 2 4 -Tn ves �m en 41:rAe , / G rMo/� Phone number. 9/0 SS! S— fid/ 3 S-'
Address:
Arc ectlEngin .y ntractor (ice cle which): L�/1 c? (-� R een 2 "� � P . Swat u
Address: _
Phone number. (rl'i 9 2 Sl `Flk/k / 82a-oY�
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Contact person: (print) C1?�� P_. s w � /I Phone number. (!F3 9"zZ— o Sim
Government agencies - NOTE: A permit application cannot be processed without the approval
signatures from any agepcy chft ed )H the left margin boxes. o _
Planning:
construction is consistent with local planning requirements
3.50-5J6-1( /OS
Phone # Date
Title
2 4
Upon completion, does your agency want to review the project/site prior to HCD finalizing the permit(s)?
Yes No If yes, this form will be re -circulated prior to the final for your signature below.
Final approval signature Date
HCD MP 514 5/09 13
DATE 6/27/2006
REPORT TIME _ i1:60E
LOCATION
INCIDENT NUMBER
EVENT NUMBER
LOCAL FIRE NUMBER r
STATE FIRE NUMBER
CASE NUMBER
RP VENNESA PHONE NUMBER
WILDLAND FIRES ❑ ESTIMATED ACRES I "J
STRUCTURE FIRE OT■ER COMMERCIAL 1
OTHER FIRE
MEDICAL AIDS
PSA/OTHER
HAZ MAT II –
Billable Incident ❑
COMMENTS
FIRE IN LAUNDRY FACILITY AT PACIFIC HEIGHTS
MHP.
i
EMD ❑ OES ❑ Interesting Event
O�G -%D - 0 1
6696;
61091 LOGGED BY
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MEDICS
PRA A10
ECC ❑
i34-7760 j REPORT METHO 911 rt
FIRE INFORMATION
FIRE INFO SENT HOW l EMAL_ BY DH J TO STA63
7 -DAY LOGGED ❑O INITIALS SO
INCIDENT NAME !IPACIFIC j
START DATE 6/27/20061 START TIME -� 1:30;
DIAMOND # r5.0
CAUSE ARSON
LAND USE OTHER UTILITIES j
ACRESf� TYPE OF ACRES ij
DIAMOND 6 ONLY $ DAMAGE TYPE f
DOLLAR DAMAGE 2000.00 SAVE 6000.00
INJURIES/FATALITIES ❑
# CIVILIAN INJURIES ISO. # CIVILIAN FATALITIES i —O
# FF INJURIES it 0; # FF FATALITIES 0 f
FC -40 10N
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New Inciaent t FC -40 ❑ DATE OF FC -40 INC
AGENCY INC #77 -j INC P# 77
FC-40 COMP DATE 'l FC -40 COMP BY
, County Notifications W EARS Hard Copy Recieved ❑ EARS Checked Agenst EARS Computer ❑
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