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NOTE: PLAN CHECK FEE DUE AT TIME OF SUBIV�f `TPL OM_ 5
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Project Address (Not mailling address)
S� Floor Suite No
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®ascription of Work
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Material/Labor 4.1, G
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OWNER'S NAME
Last (�f�ST��Y Bf7�� First
Owner's Address
Owner's E-mail Address
City
State I— Zip-- Telephone
APPLICANT'S NAME
Last � (�! �'
(•4 First I c
Applicant's Address
Applicant's E-mail Address
City
State Zip �'/ 2(� Telephone ^71 c- LlFr�C3
ARCHITECT/DESIGNER'S NAME Last First � Lie. No.
Architect/Designees Address
Architect/Designer's E-mail Address
City I
State � Zip [_ Telephoned
ENGINEER'S NAME
Last First Lie. No.�`
Engineer's Address
Engineer's E-mail Address
City
State Zip Telephonef
CONTRACTOR'S NAME/COMPANY , p p-It ,. Lie. No.�— Class C- �l
V / d�GyI ,_ r
Contractor's Address
C- _ S'
Contractors E-mail Address
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City `
State Zip �Telephone[7/
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ENERGY P/C FEE $
FIRE P/C FEE S PERMIT NO.
GRADING P/C FEE $
PLANNING P/C FEE $ PLAN CHECK NO.
ELEC/PLUM/MECH P/C FEE $
PLAN CHECK FEE $
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