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CM'D r 7©i [iut10O MG�JDD�3 MOGEL�Ii , <br /> Permit No. <br /> 90 X33 0 (0o—, �ama zapP.Jc za��aor <br /> Applicant to complete numbered spaces only. <br /> 1 SITE ADDRESS: <br /> 1 E / $ 4f # MAIL 0 R L) 07- ZIP�1 O�vl A_\V/l�3 1 .-7 --47 1 <br /> 0L-79 <br /> V��PRRR PPPHHR0 9 <br /> 2 L1/4)‘‘t tsk 19-11/N- `--3. ale i►ov, V)S-3 ,ie ntA-1-as3 'Sr- 7V,,-i5)-1W 1 <br /> CONTRACTOR -i J , MNL ADDRESS ZIP PHONE <br /> A♦ ECT DESIGNER MAILADDRESS ZIP PHONE <br /> ENGINEER <br /> . 3 <br /> 4 USE Of BUILDINGcr. i 1 <br /> -►- <br /> 5 DESCRIBE WORK: ..4N r -1 6' k ' ,� r <br /> _ T.) <br /> '^ ` C ` 1 <br /> PVC 1(S./7‘1/171,..t. P14 e C b0 <br /> 5(-C4 ? Or .),pC,L...-/-7 — .--- <br /> j (A71"--‘ -014t•v/ " /-2' 1 <br /> Of k_ VA-A--2._ E,4,..„.„...._,A,71.-4., - 4-'......A',,, k_ , <br /> 6 VALUATION OF WORK ` 1:7- 7) <br /> 1 <br /> Type of Occupancy Use <br /> NOTICE Const. Group Zone <br /> Size of Bldg. No.of Fire Sprinklers <br /> THE PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION (Total)Sq.Ft. Stories Required 0 Yes O No� <br /> AUTHORIZED IS NOT COMMENCED WITHIN 120 DAYS,OR IF CONSTRUCTION OFF STREET PARKING SPACES <br /> OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT No.of <br /> ANY TME AFTER WORK IS COMMENCED. Dwelling Units <br /> • <br /> I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION Covered Uncovered <br /> AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LEGAL TRACT BLOCK LOT NO. <br /> LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE DESCR. <br /> COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT.THE GRANTING OF A - <br /> PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL Special Approvals Required Received Not Required <br /> THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING ZONING <br /> CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION. <br /> FLOOD PLAIN <br /> }v{ WETLAND ....--- <br /> ETLANDvt�7 <br /> DRAINAGE REPORT <br /> SIONAT E OF CO TRACTOR OR AUTHORIZED AGENT (DATE) <br /> � OTHER(Spedfy) <br /> SIGNATURE OF WNER OF OWNER BUILDER) I DATE I <br /> EASEMENTS YES NO (II yes provide copy of section map) /I <br /> SPECIAL CONDITIONS // ., 6 L:'L 77. ii i 0 5 T/,c(� <br /> IMPORTANT TO APPLICANT-PLEASE READ yG Fr;,� - ,6.Z ., L.-r-, <br /> p&----.7211 l 1 <br /> SEPARATE PERMITS REQUIRED FOR: <br /> PLUMBING# APPLICATION ACCEPTED BY PLANS CHECKED 8Y APPROVED FOR ISSUANCE BY <br /> HEATING, VENTILATING �/o •9G <br /> OR AIR CONDITIONING# <br /> ELECTRICAL# CONTRACTORS LICENSE not required pending <br /> BLACKTOPPING# <br /> SEWER# & WATER# PERMIT FEE $ )' ar, <br /> PLAN CHECK FEE <br /> THIS IS AN APPLICATION ONLY SURCHARGE <br /> SWM CHARGE <br /> THE PERMIT WILL BE ISSUED AFTER TOTAL FEE $ /-6-•40 <br /> REVIEWAL OF THE APPLICATION. RECEIPT K 3 ii, 5"I <br />