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hIECK FEES DUE AT TIME OF SUBMITTAL
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OWNER'S NAME Last
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Owner's Address
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APPLICANT'S NAME Las,pLGy
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Suite No
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ARCHITECT/DESIGNER'S NAME Last
First �� Lic. No.
Architect/Designer's Address ArchitecUDesigner's E-mail Address
City State �— Zip— Telephoner
ENGINEER'S NAME Last Firsf Lic No.
Engineer's Address Engineer's E-mail Address
City State Zip Telephone)
CONTRACTOR'S NAMEICOMPANY L�_ Lir. No. FW y Class 4ETO
Conttrracttor's Address 1 ` Contracioes E-mail Address
City �r [State EA Zip ek �sbl Telephone Di, -Wei—
SETBACKS REAR to SETBACKS FRONT
SETBACKS LEFT SETBACKS RIGHT
USE ZONE DEVELOPMENT NO
PERMIT NO,
PLAN CHECK N0,
PLAN CHECK FEES S
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