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OWNER'S NAME Last
Owner's Address
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APPLICANT'S NAME Last
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City („ State ZipTelephone
ARCHITECT/DESIGNER'S NAME Last__- First—Lic. No.�
ArchitecUDesigner's Address Architect/Designer's E-mail Address
City State �— Zip Telephone-- — -
ENGINEER'S NAME Last r---_ First F Lic. No.�—
Enggineer's Address Engineer's E-mail Address
City 71 State; F Zip �— Telephoner
Lic.No. tv�ZZ I Class .
CONTRACTOR'S NAME/COMPANY / l 1 Sn`
Contractor's Atldre/rs`s Contractor's E-mail Address
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State �- Zip 92 Telephone 7 9• ! V74
SETBACKS REAR SETBACKS FRONT PERMIT NO.
SETBACKS LEFT SETBACKS RIGHT PLAN CHECK NO /`C: ?002. 2 33
USE ZONE DEVELOPMENT NO PLAN CHECK FEES $