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NOTE: PLAN CHECK FEES DUE AT TIME OF SUBMITTA 5.,. a
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Description of Work
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Valuation$
Material/Labor
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OWNER'S NAME Last .CEJ C A FlltV AN ,
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Owner's Address -
Owner's E-mail Address
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APPLICANT'S NAME Last
First
Applicant's Address
Applicants E-mail Address
City State F
Zip Telephoned
ARCHITECT/DESIGNER'S NAME Last � L�® First CIj A7j GL Lic. No. c-
Architect/Designer's Address
Architect/Designer's E-mail Address
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ENGINEER'S NAME Last
First F-_— Lic. N��nark %M
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Engineer's Address
Engineer's E-mail Address
City F State F.
ZIP Telephonel- —
CONTRACTOR'S NAMElCOMPANY
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Contractor's Addre lam
Contractor's E-mail Address `
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SETBACKS REAR SETBACKS FRONT
PERMIT N0. 0�
SETBACKS LEFT SETBACKS RIGHT
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PLAN CHECK N0. 6 W
USE ZONE DEVELOPMENT NO
PLAN CHECK FEES $
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