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Print Form VYoPhsho- Tov Combo Building & Gokow Permit AppHcation
Di Build
ing
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1� Comm]omj= �; Residential City
NOTE: PLAN CHECK FEES DUE AT TIME OF SUBMITTAL °<.F
J=Buildin �vi: Grading Draina e � Elec
g g F g � Mech F'; Plum Cu vd Cute Cu vd Fill
Project Address (Not mailing address)i Flood jai fire (� Li andslide INN/A Floor Suite No
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Description of Work
Use b }, Const Type
f
# Stgries' # Units (if Res)
New/Add SF
-
Remodel SF - �G e/New/A d
- 9 -
Valuation a
Material/Lab r1
-- -- - --
OWNER'S NAME
Last � 1�,�! -first ���,✓. �'.�!
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Owner's Address
Owner's E-mail Address
Cityf /�5�� /� I State .C--4► --- j Zip Telephone
APPLICANT'S NAME -
Last First
j� '.��>,�
Applicant's Address
Applicant's E-mail Address
-' ��i���,tw.E,Lev_,��1+s`o?-�.��"cYJer���..�at"•��-� "_r-�1rt
City
State Zip Telephone /� l --�,
ARCHITECT/DESIGNER'S NAME Last ' First I�-V Lic. No.
Architect/Designer's Address Architect/Designer's E-mail Address
City
State Zip Telephone
ENGINEER'S NAME
Last First Lic. No.
Engineer's Address
Engineer's E-mail Address
City
State ! Zip�� Telephoned
CONTRACTOR'S NAME/COMPANY ,/) / Lic. No. Class :
i
Contractor's Address
Contractor's E-mail Address
S ,
City
State; Zip F�i Telephone
SETBACKS REAR
SETBACKS FRONT PERMIT NO.
SETBACKS LEFT
SETBACKS RIGHT PLAN CHECK NO. )file-
USEZONE
DEVELOPMENT NO PLAN CHECK FEE $