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NOTE: PLAN CHECK FEES DUE AT TIME OF SUBMITTAL
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Description of Work
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# Stories, #Units (if Res)
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Material/Labor
OWNER'S NAME Last IL ����
First
Owner's Address
Owner's E-mail Address
City State Zip F— Telephoned
APPLICANT'S NAME Last 4>6nodg e,
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Applicant's Address
Applicant's E-mail Address
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ARCHITECT/DESIGNER'S NAME Last
First Lic. No.
Architect/Designer's Address
Architect/Designer's E-mail Address
City State F—
ZipF Telephoned
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ENGINEER'S NAME Last -fQJGnqJJ
j First yylLic. No. CF -70-7$+i
Engineer's Address
Engineer's E-mail Address
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CONTRACTOR'S NAME/COMPANY I) �
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Contractor's Address
Contractor's E-mail Address
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SETBACKS REAR SETBACKS FRONT
PERMIT NO. 0TV Ita • Ob (
SETBACKS LEFT SETBACKS RIGHT
PLAN CHECK NO. owe •yDz-v
USE ZONE DEVELOPMENT NO �ZO%I ' OpSrj PLAN CHECK FEES $