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OWNER'S NAME Last Lt r
Owner's Address Owner's E-mail Address
city ��� State r � Zip Telephone-
APPLICANT'S NAME Last First
Applicant's Address Applicant's E-mail Address
City �- State 7 Zip 1 Telephoner
ARCHITECT/DESIGNER'S NAME Last
C First �- Lic. No. Architect/Designer's Address Architect/Designer's E-mail Address
city�( ��(�%Z_ ( '' State r Zip 3 Telephone
ENGINEER'S NAME Last —( First Lic. No. 14aors,
Engineer's Address Engineer's E-mail Address
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CONTRACTOR'S NAME/COMPANY Lic. No.. F-- Class
Contractor's Address Contractor's E-mail Address
City state-zip F Telephone
SETBACKS REAR SETBACKS FRONT PERMIT NO.
SETBACKS LEFT SETBACKS RIGHT PLAN CHECK NC.
USE ZONE DEVELOPMENT NO PLAN CHECK FEE $