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10/04/2011 20:48 7637805011 INSTALLATION MASTERS PAGE 01/02 <br /> � , � , � <br /> /��- �r <br /> ... . . - -.� / <br /> Totsl Fee: �_ �, lDate Recei�ed: /0 5 l( �. <br /> Enbeted By: Permit#• 0//- /! � <br /> CI',C� OF Q.ltONO-BUiLDING PERNIIT.t�PPLIC,�xIaN <br /> AJI informat�on mast be sobinitted in fuA before pl9n review wiD be started. <br /> . (pteasa prrnt all infonttatinn) <br /> T''HE A,PkLiCANT IS: (cin�e one� OV4NER O N'�'RACTOR <br /> aos srrE Ann�ss: �l��O /� Qr� �1Y. zn►: 6 <br /> Will thia b a P �rade oi I�omes,Remodelers S1�arvcase Home or other Uisptay Home? <br /> ❑YeS �TO lf yes.a sp�e+ciaf sv�rt permit is rsyuirsd with�'nlice IJepar�rt m�d G�ty Cr�u�il ap,prm+a! <br /> 60 dayc prior ra ehe e�r. ShuRtle b�.e�ervic�w�71 be reqr+irud rmlc�4 cppllcav�t dano�.ctrrucc <br /> ' suJfrcrcrr�an�eir�perrki�is avQillebl� Nwr nermillad avenfs will rat be allawed. <br /> ' NA1V�E OF OWNER: �G�fi�u gH011TE: (hame) 7� <br /> ��� � <br /> MAII,ING�#DDRE.SS: C��P CiTY- Z�P= .^� <br /> CONTRACTOR: ' �IONE: �CD��O-�I 2I� <br /> CONTACT PER50N: AGER Lo I�-�$�37� <br /> MAILlNG A►DD�tFSS: : �I�: i��� <br /> STATE LiCEN5E: # EXPIIt��TON DA?E: .2 I/3 _ <br /> A,I�tCffiTEGTlENt;INEER: PSOI�i�: <br /> MAILT�TG ADDitES►S: CITY: ZiP: � <br /> ���; REGiSTRATI.ON: # <br /> TXPE QF WORK: New Ho�ae Add'ztion Accesso,ry Strvcture <br /> Move Home Remod�ellA�lteration(ie: Siding,Windows) � <br /> Anx earth movea�ent ma�y require MCiiD revie� and p�rmita! <br /> PROPOgED WO�iK(d�escribe�in dBtQin: ��t � p' 1 u�i 1 <br /> � �XI S � B� ��� 21 S <br /> STORIE�S: SQ.FEE'�'O�EACH FLOOX2: <br /> NO.OF BEDROOIV�S: GARAGE 3TA1.LS: ATTACAED DETACHED,� <br /> ESTIM,A►TTD CON�TRUCTION VALUATxON(excluding land): $ ��`'�U' � <br /> I 6ereby spply for a buiiding petmit and I acknowkedge that thc infarnaation above is aompletc and accarate; <br /> that thc work wtill lae iu confa�aance vu4tl�i�onlinances�d wdes of the City and with�e State Buitidir4g <br /> Codc;rhat I uaderstsa�d this ia no�a permit a�d ia not�o s�art ' out a pe�mit;and that the wodc un11 be <br /> in ac�cordance vritl:the a�av�d.plan. - <br /> APpJ��C�N'I"S S�GI�iATC! : A'X'�: � � j" <br /> �k <br />