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mr Residential City
o0E POofNeBUwportLAN CHECK Edacch-Buid gDivision
FP Bm SUBMITTALApplication
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F`Building r Grading ["Drainage F- Elec r Mech F- Plum Cu Yd Cat Cu Yd Fill
Project Address (Not mailing address) F Flood F_ Fire F- Liq f- Landslide rN/A Floor F Suite No
Description of Work l Use F—ConstType F_
I'` + � L .4jr5JF�ii d'
# Stories[ # Units (if Res)[_
Valuation $
New/Add SFF_ Remodel SFF— Garage/New/Add �— Material/Labor
OWNER'S NAME Last/J � First
Owner's Address Owner's E-mail Address
City l /y, 5,' State Zip � G� 0 Telephoned
APPLICANT'S NAME Last ��Firsts -
5
Applicant's Address Applicant's E-mail /Address
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city State �i Zip q-f7jq Telephone7ci5J q.?--:,
ARCHITECT/DESIGNER'S NAME Last �— First I Lic. No.
Arch itect/Designer's Address Architect/Designer's E-mail Address
City I State �— Zip I� Telephone F_
ENGINEER'S NAME LastFV/Z First 2� Lic No.
aS�K...tJ 27
Engineer's Address Engineer's E-mail Address
I e Yq w A� . w /e 7 I — -
city �r.:.�� State Zip c 2f_iE -, Telephone /-7/-, 7_//qj-
CONTRACTOR'S NAME/COMPANY Lic.. No. �i(�4�/� Class
Coontra�cttor's Address f Contractor's E-mail
/Address
City
C�- State e14 Zip �-i% ✓ Telephone
SETBACKS REAR SETBACKS FRONT PERMIT NO. XL 6 y
SETBACKS LEFT SETBACKS RIGHT PLAN CHECK NO,
USE ZONE DEVELOPMENT NO PLAN CHECK FEES $