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NOTE: PLAN CHECK FEES DUE AT TIME OF SUBMITTAL ✓ ,5<ropr,.
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Description of Work
' Use F Const Type
I
#Stories #Units (if Res)s
New/Add SF� — — Remodel SF s' Valuation $
Garage/New/Add r-- Material/Labor b ,
OWNER'S NAMELast " 1
ilgntilt First
Owner's Address vo
i—, � Owner's E-mail Address
CitytJa&&L 4�x State -
Zip €� Telephone -��
Fity
E Last
4 i First
Applicant's E-mail Address
�Lti a� State r� p
-. ZI ck-y c,� Telephone "� 3�-
ARCHITECT/DESIGNER'S NAME t �G
Last First
Architect/Designer's Address Lic. No.
Architect/Designer's E-mail E-mail Address
City
State ri— zip Telephoned---
ENGINEER'S NAME Last
First Lic.No.�..�_-
Engineer's Address s
Engineer's E-mail Address a
City
State Zip Telephones----
CONTRACTOR'S NAME/COMPANY
Lic. No. r.__—._._ Class F_
Contractor's Address
Contractor's E-mail Address
City State �.�.___
Zip (-------- Telephone
SETBACKS REAR
SETBACKS FRONT PERMIT NO.
SETBACKS LEFT S
SETBACKS RIGHT =_ PLAN CHECK NO.
USE ZONE DEVELOPMENT NO
PLAN CHECK FEES $