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BUILDING PERMIT 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 \A"'P(N � t�0'�•14 Building Address 'J-i,z¢D El;, <br />Address Lot ,,.mot " v Block <br />City yVf ✓F _r Phone 3fJ5 a�:s- Subdivision (Plat) <br />Architect/Engineer _ <br />City Phone Metes a Bounds (Unplatted) <br />Contractor Sec. Twp. Rge. <br />Address 7— <br />city Phone 1 _!Nr v. sit 'z ,•s- ltT CI <br />State License Number •G e. ZFyI 7'Cq �� ::•Y Juj <br />Expiration Date 1K CtL. LI tF PLKIS c-N <br />�•. L• 11 rlttrx r F 51 t C c <br />Building Use a�v <br />Describe Work to Be Done <br />( G l �0—r I C r-- G F <br />�I+'PCI-T `rc 6NrAC_tr I <br />Numb-:r of Stories C►-S 1 <br />Basement 'Ct_e <br />New <Additi Repair/Remodel <br />Valuation of Construction S <br />11,73 C '= <br />Signed By ! <br />For Trt-i&i' A- t�l:SSII <br />Owner Phone 35S 4•SLS <br />Do Not Write Below This Line -For City Use Dn1 <br />Date Received <br />Use Sone <br />Plan Chcck Number <br />Fire Zone <br />Valuation <br />Occupancy Group <br />Permit Fee <br />Type of Construction <br />Plan Check Fee <br />Occupant Load <br />Total Fee Due <br />Sprinklers Required <br />Date Issued <br />