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BUILDING PERMIT APPLICATION <br />Applicant To Complete This Form <br />��� I ,�- �� <br />�q3 <br />,2/�i�71 <br />If mure than one building is to be constructed, submit a separate permit <br />application for each building. A separate permit will be issued for each <br />buildin <br />0 <br />Owner � M \1' ' ^ -n ° <br />Address �. � <br />City Ph e 3r'�-�ejc4a <br />Architect/Engineer \ <br />Cit,y � Phone <br />oi <br />Contractor i�0�o��1. <br />Addr ss <br />City�-�_ Pho e '�� -��o � <br />State License Numb�r �?�-Q�-//�8 <br />F.xpiration Date �- 1 -��j <br />Building Ac'�{iress �.i(��cr�OIN�.1.�1h , <br />k��� � <br />Lot x Block <br />Subdivision (Plat) �-Q��' `� <br />Metes & Bounds (Unpla;ted) <br />Sec. Twp. Rqe. <br />Building Use <br />Describe Work to Be Done � A� � <br />� i o 1W�[�No V <br />Number of Stories <br />Basement _ <br />New Addition Repair/Remode]. <br />Valuati.�n of Construction $ <br />�rj�.� <br />Sign <br />Por -� .J� M <br />Owner Phone��%_� <br />Do Not l�'rite IIelow This Line-For City Use Only <br />Date Received • Use Sone <br />F�lan Check Number <br />Valvation��Oi�lM � <br />Permit Fee �¢-�— <br />Plan Check Pee <br />Total I'ee Due <br />Date Issued <br />I'ire Zone <br />Occupancy Group _ <br />T��pe of: Construction <br />Occupant Load <br />Sprinkl�rs Required <br />