HomeMy WebLinkAboutXR2023-1038 - Permit ApplicationPrint Form Worksheet for Combo Building & Solar Permit Application o�EW�q>e
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NOTE: PLAN CHECK FEFS DUE AT TIME OF SUBMITTAL
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Project Address (Not mailing address) F_ Flood r Fire F_ Liq I— Landslide F_N/A Floor Suite No
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Description of Work lj 1K OL stti X
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# Stories #Units (if Res)
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New/Add SF Remodel SF Garage/New/Add a/New/Add
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Valuation$ ��o,DQo
Material/Labor
OWNER'S NAME Last VAN _X Ll L OF F— First pTqz-
Owner's Address Owner's E-mail Address
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City M�- State ( Zip �}/„/ Telephone rj�� SUI
APPLICANT'S NAME Last First
Applicant's Address Applicant's E-mail Address
City State Zip [_ TelephoneF
ARCHITECT/DESIGNER'S NAME Last lid y14First FToM Lic. No. FC22 56 7
Architect/Designer's Address Architect/Designer's E-mail Address
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City MN State I OA Zip �7 5 Telephone 7/Y 73 c;7;3
ENGINEER'S NAME Last R S First Ii� L�^ Lic No.
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Engineer's Address Engineer's E-mail Address
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City I S,*R qn/k State Zip 9 /— Telephone 657 335 — zf l e�
CONTRACTOR'S NAME/COMPANY Lic. No. Uf � j5 Z Class
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Contractor's Address Contractor's E-mail Address
City State F_ Zip Telephone F_
SETBACKS REAR SETBACKS FRONT PERMIT NO. X�Z��h
SETBACKS LEFT SETBACKS RIGHT PLAN CHECK NO.
USE ZONE DEVELOPMENT NO PLAN CHECK FEES $
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