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�' "�' t:l'!'Y UN' YKlUK LAK� K�1iLll1NtT Y�ltMl"i', llate Kec'd
V I � TEMPORARY CERTIFICATE OF ZONIAIG COMPLIANCE
AND UTILITY CONNECTION PERMIT
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'. „'�" �'` pERNIIT NO. / --� - 3
2 Pfntc Ciry Z .�
3. Ydloa Applicant
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ADDRESS ZONING ��,�>
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LEGAL DESCRIPTTON (off•►ce use onty)
LOT BLOCK ADDITION PID
OWNER � � � ��j P � hone
(Name) � (�' )
�A�S, �'� 7 g Gv���J �D��:�� � � - f
r
(Co�mp Name) � � 1��� �(� i�i�l �L� ( t�'f.} ? C1� (Phone) `-�� �� �"' " �
(Contact Name) � � " / e.S (Phone) � " '"�
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TYPE OF WOBK ❑ New Consavction �I�eCk �Po�i► Re-Roofit�g �Re�iding QLower Levei Finish ❑ Firep3ace
❑Addition [�Alt� Q[Jt�ty C �
CODE: DI.B.C. OLB,C. ❑ 1uTi5c: �
Type of Comstiuction: I II III IV V A B /� Q��
Occapa�uy Grnnp: A B E F H I M g S U PB.07ECT COST/VALUE S 6
Division: 1 2 3 4 5 (escl�ieg land}
I�r �'r rn�c i� r,�n�a �� u� ����o we �c o� g►y mo�a� o� �a �xr. i�,o �;ry maz t am � o� a� �a a�r r� ct�
above- and that confo:m to a!E ez�ng �te and 1oca1 Iaas and w�7I p�ocetd in aaroidanoe wiih sobnoimad plans I am aware 1ffit the bu�7d'mg
ofl�t � ��e ro� �' , I heieby agee ti�t t� cuy afficia! � a de�ee map e� upon fiie pmpeccy w ped'a� �' �'��
X 'G6�7Z� 2 �
s;�awre com�cxor's Iaoense xo. 1�a�e
Pernut Valuation Pazk Support Fee # $
Pennit Fee $ SAC # $
Plan Check Fee S Water Met�r Size 5/8";1"; $
State Surcharge $ P�essune Red� $
Penatty S Sewer/Water Canneaion Fee # $
Plumbuig Pennit Fee S Water Tower F� # $
Mechanical Pecmit Fee $ Bu�der's Deposit �
Sewer 8c Water Peimit Fee S Other E ,
Gas Fireplace Pecmit Fee � TOTAL DUE S�9 '�'
Tlus app�ion seca�es Ya� � P'eo�t wLeaA�i Paid N
D�dte d B
s�ta� offi«� n�
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when sig�med by ffie Cgy Planna ca�es a�apoporay Cati6caoe af 7taom,g mo�e aod a6ovrs c�tntcoion �o eomm�oe Be�om oocu�paocy, a Cew6ca�e af Oacapancy mtBt be
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