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APPLICANT'S NAME Last First'
Applicants Address Applicant's E-mail. Address
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City�— State `Zip
ARCHITECT/DESIGNER'S:NAME LastI I First
Lic. No: -
ArchitectlDesigners Address ArchitectlDesigners E-mail Address
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City �— State Zip
Telephone
ENGINEER'S NAME Last First
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Engineers Address Engineer's:E-mail Address
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State'
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Telephone
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CONTRACTOR'S NAME/COMPANY �p� l/f_ (
Lic. No: j Class
Contractors�Address :Contractor's E-mail Address
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177
City ��n � State Zip'
' 705
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SETBACKS REAR SETBACKS FRONT 6D
PERMIT NO.���,
`SETBACKS LEFT ';. �� SETBACKS RIGHT :
PLAN CHECK N0-
'ISE ZONE " TIG - -7 DEVELOPMENT NO.
PLAN CHECK FEES $