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BUILDING PER14IT APPLICATION <br />Applicant To Complete This Form <br />If more 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 />building. <br />Owner % f,i ,-' �v�Y�7f Building Address i0,�/ C'e�L�✓ <br />Address �? a D 4 L fm n r -e Lot f - � Block <br />City - � ij' Phone2�9-Q$// Subdivision (Plat) <br />Architect/Engineer $ -1-14 <br />City ;o.:, /Phone Metes & Bounds (Unplatted) <br />Contractor O yo as Sec. Twp. Rge. <br />Address <br />City Phone <br />State License Number <br />Expiration Date s <br />Building Use -'F0 vh�; M/9 %n 4- <br />Describe Work to Be Done <br />Number of Stories <br />Basement <br />^New Addition Repair/Remodel <br />Valuation of Construction $ <br />Signed By(_�For <br />Owner Phone <br />Do Not Write Below This Line -For City Use Onl <br />Date Received <br />Use Sone <br />Plan Check Number <br />Fire Zone _ <br />Valuation <br />Occupancy Group J --z- <br />Permit Fee <br />_ Type of Construction - t._( <br />Plan Check Fee <br />Occupant Load <br />Total Fee Due <br />Sprinklers Required <br />Date Issued <br />CI tY Or EVErtt I I <br />APPROVLD FOR BUILDING PERMIT <br />Jate /z'7/-7�. BY <br />Y <br />