HomeMy WebLinkAboutX2021-0582 - Permit ApplicationI�'Printform' A ' `- Morksheet WCbinlio Building & Sidlar Pb'rrhit► A' plication"
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Comm'( Residential NOTE: City of
CHECKOF ES DUE AT TIME OF (SUBMITTAL
Building r Grading rDrainage r Elec rMech r Plum Cu Yd Cut F_Cu Yd Fill F
Project Address (Not mailing address) r— Fioo
Liq r Landslide rN/A Floor Suite No
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Description of Work
Use Const Type
# Stories nits (if Res) r
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Valuation $
New/Add SFF— Remodel SFF Garage/New/Add F—
Material/Labor
OWNER'S NAME Last G A / N
First I �� If Al
Owner's Address
Owner's E-mail Address
City Mt Wf74fL Y .g am State CQ
Zip 92 6; Telephone
APPLICANT'S NAME Last
First
First
Applicant's Address
Applicant's E-mail Address
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City State State
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Zip �Telephone %"�-Q aS1eeoft7_
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ARCHITECT/DESIGNER'S NAME Last G7 First C/j/i T(dL Lic. No.
Architect/Designer's Address
Architect/Designer's E-mail Address
City ti 44 (1:17r 6�4e_li State
Zip 72 ro fob Telephone %`/q os/'$�7 5
ENGINEER'S NAME Last spp. +
First �(� Lic. No.762157/
Engineer's Address
Engineer's E-mail Address
City /( (� Hc�_ State I
Zip �Z$dy Telephone 7/�
CONTRACTORS NAME/COMPANY I
/V ( Q i 1�� e ��S o ��y. icajo.�Classr
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Contractor's Address
Contractor's E-mail Address
City State F
Zip I Telephoner
SETBACKS REAR SETBACKS FRONT
PERMIT NO.
SETBACKS LEFT SETBACKS RIGHT
PLAN CHECK NO.
USE ZONE DEVELOPMENT NO
PLAN CHECK FEES $