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BUILDING PERMIT APPLICATION <br />ApOicant• To Comp].eLe Tlii form <br />If more than one building into be construct6de submit <br />a Bel rucc)cfopnrnte rrcach <br />application for each building. 1' <br />building. \\ Building Address <br />Owner�Af.��_ ti_��c� y ` Lot Block <br />Address �;� i= =ac.c _ <br />i- .15�• - o Subdivisio <br />Phone n <br />] (L'lpatl <br />city �,� e w= "cr — <br />e <br />Archi`_ect/Engineer, <br />Phone ?cam; ZCf' Meles 6 Bounds (Unplat•L•ed) <br />city ail ec..R —Twp. _ Rgo• <br />Sec. — <br />(� <br />contractor?;; , <br />Address 1` �r • ► �l AJ <br />city Phone X <br />State License Humber. <br />Expiration Date S% <br />• Building <br />USe r U f r <br />Describe Wcr1; to Be Done <br />WHO=: PLOT PLAIT Oil REVERSE SIDE <br />Number of Stories — <br />Basement L <br />�Nea Addition Repair./ReModel• <br />valuation of Construction $ <br />Sig end By <br />For <br />2 <br />Owner Phone 1.-y ehI'�I_ <br />Do pot Tarite Below This Line. -Foy ity Use on, <br />-- Use Sone <br />Date Received Fir(: Zone <br />Islan Check Number `7 3 <br />_ Occupancy -Group <br />Valuation — Type of Construction <br />Permit Fee occupant Load �- <br />plan Check Fce Sprinklers Required <br />Total Fee Due <br />Date Issued <br />