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NOTE: PLAN CHECK FEES DUE AT TIME OF SUBMITTAL
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Description of Work
Use Const Type �!
W�J1!1lU L 1 15 � ��� � , Sl'+., s " ,•t.y � ^° e
j # Stor[esF # Units (if Res)
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i� Valuation $ i
New/Add SF� Remodel SF I Garage/New/Add Material/Labor F-0
OWNER'S NAME Last e
Owner's Address
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city 0 t t^ ..._._ State _
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APPLICANT'S NAME Last I 1_), ;; ._
Applicant's Address
City l d `in State I
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ARCHITECT/DESIGNER'S NAME Last
Architect/Designer's Address
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Cityi7 r`ftIbOk State � f -
First I srd t�
Owner's E-mail Address
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Zip
Applicant's E-mail Address
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-400-
Zip
40v -
Zip `j. vl % Telephone 1 4,31' � Y
First Ut^ Lic. No. �—
Architect/Designer's E-mail Address
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Zip r_.. _... Telephone iii _
ENGINEER'S NAME Last First Lic. No.F
Engineer's Address
_._... --. _- ._.... ............... -
City State
Engineer's E-mail Address
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Zip Telephone
CONTRACTOR'S NAME/COMPANY Lic. No. 7 ` t C� ClassF 71
Contractor's Address Contractor's E-mail Address
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city � _r J ` a., Telephone
Ci c� tw t� State L Zip n
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SETBACKS REAR I SETBACKS FRONT f PERMIT NO. ,,- j
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SETBACKS LEFT �, t SETBACKS RIGHT PLAN CHECK NO.'
USE ZONE DEVELOPMENT NO PLAN CHECK FEES $