HomeMy WebLinkAboutPV2021-110 - Permit ApplicationNOTE: PLAN CHECK FFFc
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Project Address (Not mailing address) fX_ Flood
m of Work
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AT TIME OF SUBMI AL
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Cu Yd Cutl Cu Yd Fill
Liq FX_ Landslide (XN/A Floor Suite No
Use Const Type r---
# Storiesr— # Units (if Resf —
New/Add SF�—�-Remodel
SFr - Garage/New/Add r--- Valuation $
Material/Labor
OWNER'S NAME Last
Owner's Address
First
Owner's E-mail Address
City F_—_..
.:..State
Zip r _ —_ Telephoner-- - -
APPLICANT'S NAME Last
Applicant's Address
First
-
Applicant's E-mail Address
City
State zip r--- Telephoner-�_-----
ARCHITECT/DESIGNER'S NAME
Last First---- j
Architect/Designer's Address
.
Llc. No.
�--"----—
Architect/Designer's E-mail Address
City
State �—Zip
Telephone[--_--
ENGINEER'S NAME Last
First Lic. No fr
Engineer's Address
Engineer's E-mail Address
City
State Zip j�---- Telephone _ -`—
CONTRgCTOR'S NAME/COMPANY
/J Lic.No. 02-342-7 Class
Contractor's'dv
Address
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Contractor's E-mail Address
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State FC- 1E Zip c' y 6 1-4 TelephoneF7
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SETBACKS REAR
SETBACKS FRONT
SETBACKS LEFT
PERMIT N0.
SETBACKS RIGHT i
USE ZONE
_�_ PLAN CHECK NO.
DEVELOPMENT NO
PLAN CHECK FEES $