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1 � NOTE: PLAN CHECK FEES Dil UE AATITIME OF SUBMITfRL �� ✓ �� /U
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Description of Work_ 6 --- Use Const Type
_ # Stories #Units (if Res)
Valuation $
New/Add SF I Remodel SF[ Garage/New/Add--� Material/Labor
0WNER'S NAME Last I I "' ;�A lU0,4L M _
Owner's Address
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city
State
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Owner's E-mail Address
Zip - q' ; �01 J Telephone -_ -
APPLICANT'S NAME Last yGG"� First - --
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Applicant's Address
City 111/'A-__ - ---- State J
ARCHITECT/DESIGNER'S NAME Last f-W-AX
Architect/Designer s Address
City %V�/v �/qRY� I State �.
ENGINEER'S NAME Last
Engineer's Address
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City J State
Applicant's E-mail Address
Zip Telephone
�� First �._ Lic. N-
Architect/Designer's E-mail Address
Zipj D �(> Telephone �t�. L .____.__.I --- --
First 'A�I I I Lic. No.
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Engineer's E-mail Address
Zip �12
Telephone 5� 1. (�'i-� - --- 2 -qo
CONTRACTOR'S NAME/COMPANY Lic. No. !� lass
Contractor's Address
City-��LLt��li/ - --- State
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SETBACKS REAR
SETBACKS FRONT
SETBACKS LEFT SETBACKS RIGHT
Contractor's E-mail Address
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Zip E525 Telephone yy _ f�`
PERMIT NO.
PLAN CHECK NO.
USE ZONE DEVELOPMENT NO — PLAN CHECK FEES $