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<br />" • : • T�pplicanL To CumpJcCc Thi:: ?ocm , !
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<br />•� If worc tLin onc buildi.ng i.^, to bc contrur.t•cd, submit n.^.epn[atc pci-mit applica-
<br />� ., 'dcn for coch buildi.r�. d separ�tc ycrmit will bc i:;sucd 1'.or mch builJi.uq. .
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<br />. � � D.�ncr `i,. i ;� ' - , J% � _ � lluildinq Addresa
<br />' � �dzc�a = I.ot• / � IIlock � '`
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<br />City � :, � �-�. .- Phone '- : , s;� ( ; �ubdivi�ion (Plan) � : ,�� � � , .
<br />� ' • I.rctiS.tcct/i:nginccr � F.��,,� I '-- . � _ '
<br />"� City Phonc I3el•cs L Leunds (Unplatted) ' �
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<br />- :,'. Co:it�actor , :;cc. Twp• B9c —
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<br />.. •' -.City .Yhcnc -llni.lding Use _,,.�.� ,' �- /i�� : �'.'�.
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<br />-� ���:� � Stzte,Lice�u^e tfa^iber Describe S4orS: to De-0one� i:� /'�.� o�_�''����
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<br />• �. �I Er.Pi.ration Date � �. �'- % - �.',. <� ,�� � , < .f�.� , /� �", ,
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<br />�~ : �" . SI'STC11 PLOT PLJ,?I JELOf�7 � ' � . . . , .
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<br />� IIse of lluildii�y �_...., '. .fi ��. . i-
<br />i. � ��1 ' .. , ' _" � . � ❑17ew ' ❑ hddition � Rcpair/Rcmc::cl
<br />. � • " . . . • •Caluation of Construction $���
<br />� - • ' - . - i:PL'OT PLA2d REC?UIRT."�:.::TS . . .
<br />� '�t � • � � . • . . • ' :I.ndicate lot .^,izc, nane of. streccn,
<br />'. � '� �i . � : � � . . � .3.nd'.cat'c location -ar.c o:i.cth o�
<br />. ..� - �� '" - � �� � � . • a17.cys, 'locatc ar.opo�ed a;.d all �
<br />;,:� - . . . - � .exi:�ting 5u�ia�: y_ sn�•.� d:���nces '
<br />_ i q� ' ...'. - �_ ,e . : . . _ . �. . -.Lv prcperty lines, si,ou distancc�
<br />� � �t • . 8 . ' - ...between buildings.
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<br />� ' ' � � � � �Lot size x ' .
<br />� � . + n\�.,������:'� . � • � Sot- area � Sq. Pr. .
<br />. --�- . D �� `l � .. ' �Siae of Fticig. . Srt_ Pt.
<br />.; •� �j 19i5 • iiu,�i,�: �r: :;t�,:x�,. --
<br />. �.: . ;' p�gC 2 � �, Dase:nent --
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<br />� ; '�- ' OF � Signcd IIy -
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<br />Da[c S::ccived 1� -".. �� ; � l� 1
<br />:. .-. Plan C:�eek `:ucbcr - �.� ` '
<br />\'alu.:ion '_.Y_L'���. Cn,Sf- _
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<br />1'lan Chccl: 1're ____ —
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<br />so:al rc�c uuc . _�
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<br />',I;Iii'iOR Ci9'Y ilR::
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<br />Pirr_ Zonc S�;__�.__..
<br />Occ•.ronncy Grou�� 1 ____.
<br />'ly�ie of ConsfivcC.ion V �1--F�____
<br />Occup:mC I.o�d _��__.. -
<br />Sp: i.�:l:lcr : f:�,quiLrfi��' (J�-i-�/ _F#rF��----___
<br />• • APPROV[D FOR BUILDING PERMIi
<br />: Date--U-r��/'_�•��.pv- � • r
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