HomeMy WebLinkAboutXR2022-2090 - Permit Application (2)Print Form Worksheet for Combo Building & Solar Permit Application oE�`WPoRm
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NOTE: PLAN CHECK FEES DUE AT TIME OF SUBMITTAL
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Project Address (Not mailing address) 1- Flood r Fire F7 Liq r Landslide 1-N/A Floor Suite No
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Description of Work
TLE Use ConstType
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# 5tones# Units (if Res)s
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Valuation $
New/Add SFs Remodel SF boo St�Ff Garage/New/Add �— Material/LaborFS
OWNER'S NAME Last O1RtLIY
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Owner's Address Owner's E-mail Addressy
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City N'E WP6TZT _CiEr+e_V} State Zip � 63 Telephone
APPLICANT'S NAME Last
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Applicant's Address Applicant's E-mail Address
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City C oS t1q *�ESFi.__ - State C+°t — Zip �(26Z -_ Telephone 7q-k97 23S-off
ARCHITECT/DESIGNER'S NAME
Last t�VINA First Rtc-ATz-Co Lic. No. 30t61
Architect/Designer's Address Architect/Designees E-mail Address
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city ITzVt+rE State.4- Zip �1Z6fY- TelephoneFe
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ENGINEER'S NAME Last First �® Lic. No.�
Engineer's Address Engineer's E-mail Address
City State Zip �— Telephoner
CONTRACTOR'SNAMEKOMPANY-`EPrtn V\-T1MO Lic.No. y4y�yZ Class
Contractor's Address Contractor's E-mail Address
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City ME5 } State cA Zip IZ6Z'} Telephone ir{`1-66�-SZ`t3
SETBACKS REAR SETBACKS FRONT PERMIT NO. 016"14910
SETBACKS LEFT SETBACKS RIGHT PLAN CHECK NO. {t.Ou, .f4j?/
USE ZONE DEVELOPMENT NO PLAN CHECK FEES $