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<br />-� ' �' i ' ,. , • � Rnplicant To CompleterThis :orm �' l�Ss`�� ' �:� � � . .,,'y' .
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<br />, • Y! more than one buildinq is to be contr�ir, �d, submit a separatc permit applica- •
<br />., tion for each buildin3. A separate permit C�11 be .,sued For each buildinq.
<br />. � ' Ot�ner �t_G „I ) 1�7��5 • -I-r� c Suildinq Addzess � .
<br />� . �'. � 1lddresa _-1 1 �Q RN�l6r7,7.n, � W+{'� Lot / 3� Hlock ' ,
<br />-, . City �,i,i�rC�7 Phone?,��- �yu'U SubdiVision (Plat) 7,��l�+ec s� %� «s 1�� �,
<br />• � - Jsthitect En � . -� � . ' • , • ,
<br />_ J gineer �nwi'r7�-G �
<br />_ .'.',;, : • "_'� C1ty �tlRnzrU� Phone 2'SZ-tX�o Q Metes 6 Bouads (Unplatted) ' •
<br />_ �;�•: Contractor � r°T"A CrOAJ 5 i Yu.f t i^, o�� Sec.� Twp. 2�� Rge 5� . '
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<br />_ � ;, : �• lddzess I�. �� ��� r 44 �f- • . ,
<br />.�� City'-/�MiJ!Sv�«1- Phone /,ti"�l ^U�1 S� Bnilding IIse ZF�r'7�1 � ��^.-��3:`'�.; =�^Z
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<br />••� �'�} State, License Ncn6er 223 - d I- 1"z5 5 5 ,9escribe Work to Be .Done �`�
<br />: .• .1 Hcpiration Dat� '�l I i � �. G, '' f Lr� up �7/_ ��-5 iLr-r /L..r t .' •. - .
<br />� t.�' - SRETCH PLOT PL.1N BELOT•T' • �
<br />�-t.-�� •. „ , .. � . . .'
<br />�. . . - .. _- ilse o£. Buildirig ���M � � A-LPs r-�
<br />a- � � . ,_ � �New ❑ Addition (�Repair/Recio`el
<br />. . � .; � . . . . ' i
<br />; • . " " . � • ;' "• Valuation of Construction $ � �j, v a U
<br />� '• . . . .. - .. . : I .. • -
<br />�- . - .: .'. -, � - - PIAT PLAN REQIII_TiE�lE.ITS . = -
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<br />�• ; • • ' � , . ' � • • ' ' Itldicate lot size, na�e of streets, �
<br />_ :.! � _ : : , -: �_ - ' + � •indicate locztior. and widtn o� .. •
<br />,, _ ti•• .. : alleys, 7.ocate pronosed ar.d all
<br />' '`( ' •' existing bnildi.-.gs, sho:r dis:ances �
<br />_ ? 3 =1 � ' .�:^'" -� v. � : ' . .�'=.. ' . . to property lir.es, show distances
<br />• S : ' : � " between buildings. •
<br />. ' . . . . � 22��-s.v Lrr2 ' ..
<br />• ;� '• _. . a' . . . ' . . . , iAt S1Z@ X ' .
<br />. -• s • • ' • " ,' .Lot area Sq. Ft.
<br />' .•, ' r, = , , ' . ,. 'i;. .. . . - . . Size of Bldg. Sa. Ft.
<br />' � `�j . . ' . • Number of Stories
<br />. f: .
<br />:_ - i� . - . . Sasement �
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<br />'� _ ' . � • • . . . Signed BY P�.,. r H�-.2-0:�.�'-�h'
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<br />_ . . . . . � ... �'or 1 �� a,� w Qn.� s . � c •
<br />. - Owtier Phone i C4 -U�
<br />..' � DO :10.^ h':2T_T� H?LOE7 THIS LI:dE-?OR CITY US 0;7L'1 �
<br />. Dnee Seceived �f I IZI%`�^ � IIce•Zo.ie . .
<br />' Plan C;�ec:: :7ucber �% � — 4--Z-C� ' Fire 2one '
<br />•. Yaluation � .i'�J� ��� �� Occunancy Crov,�
<br />� Peznit Fee �cJZ � � � � �Type of Canstruction
<br />' �Plan Check Fee -�7�j. � �� Occupant Load •
<br />. ��
<br />. Total Fee Due `� `� SprinY.lcrs Rer,uired ' ,
<br />Daic Issucd . • ' • • • CITY bF. EV.�R�I'T
<br />• •• . � . • APPRO'JGt�"fuR.,LUf{�DING PERNIIT. , .
<br />� �..
<br />. : , . ; , Date �� 1-�('�.a--_•By � ' � �. � .
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