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A <br />CI'1.1' OF IiVGl;I 1'T' PEIt?•fl'1' P.0. /Yk 5/ �2- <br />llA'Alt' E:!T or C:::. ;]ITY <br />ISC111.U1GG PERIM' APPLICATION VALUATION <br />1)A'1'li �;N- /7. ' 3 PL•'I5 IT VEEr <br />ADDRESS OF CONSTUCTION WORT: <br />L1iGAL 1)IiSCRIPI'IO:y. L01' f 9- 20 I1LCICR 1'Lh1' ��c > _ _ . <br />UNPLATITD DESCRIPTION: <br />-- IZI;;';ODEL -- <br />BUILDING DESCRIPTION: NE{J 6A)DITIOX�� or REPAIR <br />occuiviNcv or, usr ct- <br />IS THIS A CHANCE 02 P,UILDI::G OCGi(FA:;CY: <br />CONTWiCTOi: <br />MAIL) NG Z� <br />ADDRESS v � 2-(3 �( <br />PUO:;E NU;M)FIR <br />111IMITS IN STORIES <br />YES FO , <br />owizER <br />1• ULIXG <br />ADDRESS <br />PHONE NUlffll .P, 1 s 2- 7-3 0 C <br />CONTRACTOi�' S LICENSE Nurr rrR 2 2, 7 > 6 <br />SIM"ATUi:6�-)LI-t<-- <br />NOTE: THE APPLICA;T S.UOU FILL Ill ALL /.I;OVF DLkl,;(S CO%:_LP.T%TY I:;CLUDINC Till-' PLOT PIAN <br />S1:ETC11 02? Ri %R Oi•' ':IiIS S'1i:rT. 'THE APPUC.'L;T IS R1iSM.%SIBL1 FO:: ALL IXFO:-' TION KI:IC11 <br />IS rU1:?II31IFD ON Tii:: AP"LIC.'.'PIO::. ANY CU'.::GCS IF, T1:S. INFO u'IATIO:., PLOT PM." OR F.LI LDIi G <br />PLANS SIIALL DE' SUI:_ifTf:D TO THE INSPECTION DIVISIO;: FOR APPROVAL BL••FOR% ;:OCEEDING <br />WITH THE CONSTRUCTION li0'UC. /J .__�. <br />APPROVAL: <br />1. I'I r ]'NING. 1. ✓ DATE <br />2. ENGINEERING <br />TF.AM"! DIVISION <br />MITER s:.I:V.ICE <br />Mll)!1: S1111VICE <br />PUBLIC SERVICE SL•'C'1'10' <br />3. INSPIXTION DEPAT:'T1• ENT % <br />fit. PINE MARS11A1, <br />-7-73 <br />C� <br />NOTE; ALL CO::o"'l'I:UCI']OJ WORT: SHALL COMPLY WITH APPT,I:CADLE CODES, NOTES ON DRAWINGS, AND <br />INSPi:C.TIONS <br />