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J� <br />� � • _. ��; � �_ , � <br />noiLnzr:c rsRt��z�r nrrLrcnTroN '-� : � ` <br />nPPliclnt 'Po Complete This P'orm f��,l���� <br />If more chan one buildinq is L•o be constructed, submit a separate permit <br />app:i.icaL•ion for each building. A separ.ate permit arill be issue3 for each <br />building. , �' <br />Oomer L.��NHiPD y��f�C�Jf�SEN Building elddress /$OS �!//_L %'/ ��L <br />Address �pg03 /sT D�'� S F• Lot 3��Y S IIloc}: j� _ <br />iTr?�3� T"'�122 E <br />City �/%�'E7T� Phone 3S'3 �/3�� Su�c�iivision (Plat) Cj+���<-�v ,)i1.�,f% <br />)lrchitect/13ngineer YD�C''/C" -'�r SeH�'NKE �i �p�T%GN <br />City Jf�M•`IICA.N�i�. Phone '— Mates & �ounds (Unplatted) _ <br />o!r✓�v� ' <br />Contractor 5�1,� �E-= ,�� � ' Lz=� Sec. Ta,p. _ Rge. <br />Address _ — <br />City — Phone J _ — — <br />State License Number '— _ _� — <br />Expiration D�te <br />T3uildi.ng Use S/,�i.-�f�_Mi� �PE�, <br />DescriUc S�'ork Co Be Done <br />Cc,�s�L,•T�cN n.•�= S:�vc� c— <br />i=yM/L�'� GPFSi/�NCL—C _ _ <br />� Numbcr of Storics / __ <br />Ba�ement i7/o,vF' __ <br />New Addition Repair/Remocicl <br />Valuation oL Const:uctioii $��o�`�' <br />Do Not [�ri.te I3eloo.+ <br />Date Received /L 3 7 � <br />Islan Check Nu.mbei 7G.�� / Z% __ <br />Valuation `L9 /?7. `''� <br />Pe•:mit Fee /Z 7• � <br />Plan Check Pee Lo3• �'v _ <br />-a <br />Total T'ee Due / �/ �..�' <br />D.itc Issr.ed <br />Signed By �(/i*rzeriz�� �i�i'��v <br />P•or <br />Owncr Piionc 353 -i3cr� <br />s T.inc-I'or City Use On1Y _ <br />Use SoneF-/,r.J�i�vG.�M«� ww <br />Fire Zone #3 <br />Occupancy Group _ _ <br />'Pypc of Construction _ <br />Occupant Load ___ <br />Sprinklers Required _. <br />