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�i;-Og-96 M0�[ 10� 16 GIERTSEN COMPANY FAX �[0. 61�5460623 F', 02 <br /> � <br /> T4i81 �"'�e: $ ' � -; � ,�]2�Cc Receiv�d: < <'c� <br /> Enter�d $y: ���� — <br /> ��– _.,..— Permit#: `��-__(: <br /> c.rT� �� oxoxa - �U��.,��N(i PERM�'�` APPI,ICA'�'I�N <br /> �� fnfurmation� mu�t be submitt�t� ia ft��! h�Y�re pIari review w�l! b� started. <br /> �IEfl.5��71'!i!t Qjl II2f�r177LltiC111� <br /> -� �--------...�...._............�_.----------�-- <br /> �-----_..,....-------------�.__..---_-__ <br /> 'I'FI�A�'�'LiC�NT` IS' (circle nne) OWNER UR CQN�'RACT�]� <br /> sas s�� a���,.��. �_..�.� - ��ss._������: 5�� 1 <br /> NAME QF UV�'N�;R• ���, �; ' � � � PHO?4'E� (hame) <br /> ��AII.,ING ADD�SS: � (work}��:�'S� - --��$�'�-� <br /> � _� c�:�._.��.2�rn...Y.�.�,/ <br /> � <br /> [',U�'I`#tAC�t'OR: e,��' t � � L-p PHC�i�k�: � �� D O <br /> CUN'I'�1,CT�k��a�ON�' � � L c� MOBTI.,�/PA�`,�R�� '_��_ <br /> �.�.rnr��n�:�s�: �� �� -r �e�e�c�TY; �C P��� ��.��� <br /> STATE L�IC�rISE: # / 7 �� <br /> ARCHI'I`ECT/EN�LN�E�; P���;: <br /> MAII,�NG ADDRE�: CITY: ��': <br /> NAME: �� �GIS'I'�#'i�f3l�'# � <br /> TYPE 4�' WURK: New Additi0ri Accessc�i`,V St�uc�l.tzc <br /> Mnve __ �'Ren�ock3/��tozatican�_ Lattd A�ter��ion � <br /> P�OPQSE�W{]�tK(ciescr in dex�ttn. -, �_"�� <br /> -- C�� ��(, �� _ � _....� <br /> S'I"OItIE�: SQ.�E�'C1�'�AC�FGOC�R. <br /> NO. OF$E33Rt�OMS: � GABAGE ST,ALLS: AT'T. DE'�. � <br /> ES'X'IMAT'ED C4NSTRUCTIQN VAI�UA'I'��1V{excluding land): $ � - c�--c.. <br /> i t�er��y aggiy for a bnilding perriiit azac�I ac�owledge that the iztformatiqri.above is co�up�tl'e �.z� <br /> accura[e; [h�ti tl�� woz'k wfi� be� i� et�nfvt'rttance with tfte ordinances and cod� of th� City atuf with <br /> thc State Building Code; that T understand this is n,ot a permic and work is r�vt ta scart withaut a <br /> permi�; and t}tat the ���rk will be in aecordatace witl� the appxoved ptan. <br /> � <br /> AFp'LICAN'�''S SIGI�TATUR�.': � ,�. - /y � DA.TE` ;�� `�` <br /> NO�'�! FccrQde �Y�mes el� ts requlre ,Se ute petmit apprpval by Pvli�ce Dep�cr•tment arid <br /> City Counc,�X 6U days prior tv the ev�nt. Non permitted events wi1X rrat be allnw�d. <br /> S��i=aN �,01l.0� [� LS�$0 96I60/�i, (11,��1�1�,7ta � .,,,...,.. ._ , . _ . <br />