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White 2, Pink 3, Yellow File City Applicant DIRECTIONS SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom) 2, SITE ADDRESS 418.:.. v.""'.............- Ave- t 3, LEGAL DESCRIPTION 1, DATE Nv 2 '''''''-1 ~-k t:t tD? BUILDING INFORMATION 11, SIZE OF STRUCTURE (Heighl) (Widlh) (Deplh) 12, NO, OF STORIES ~~...~- BLOCK I ~J: I AJ.Lk.... PID,jJ -19'1- tJ{)Y- D LOT "f + .;- ADDITION 13, TYPE OF CONSTRUCTION 4, OWNER (Name) ,C. -:ri...... nJ-.l,.:.-K 5, ARCHITECT (Name) .._Ie... 6, BUILD~ 7, TYPE OF WORK (Tel. No,) 14, FLOOR AREA APPORTIONMENT USE 's..- 1\1.,,! -S"",43 (Tel. No,) I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the above mentioned property and that I cons u ion will conform to all existing state and local laws and will proceed in accordance with submitted plans, I am aware that the ui 'n I ke is mit u hereby agree that the city official or a designee may enter upon the property to perform needed inspections, (;(;0 J(, 87 Ueense No. Dale (Address) ~)f Septic 0 Addition 0 ,I.-.. 9, PROPERTY DIMENSIONS (Tel. No,) Lf4. - '!fJ80 New Construction 0 Chimney 0 Mise, 8, PROPERTY AREA OR ACRES Sq, Ft. Heating 0 Plumbing 0 Finish Attic 0 Residing 0 Reroofing 0 Porch 0 Finish Basement 0 15, NUMBER OF OCCUPANTS OR SEATS OCCUPANTS SEATS 16~STIMATED VALUE " Iroeo. Q) 17, COMPLETION DATE 10, CULVERT SIZE Depth Yes No FOR ADMINISTRATIVE USE SETBACKS: Required Actual MATERIAL FILED WITH APPLICATION Fronl Back Side Side SOIL TESTS o ENERGY DATA o PROPOSED GRADE FOUNDATION IN RELATION TO CURB OR CROWN OF STREET o#-r-c.<.. Sp<U-~ OFF STREET PARKING SPACES REO, SPACES ON PLAN PILING LOGS 0 PERCOLATION TESTS 0 PLANS & SPECS ~ SETS 2. USE OF BUILDING SURVEY o COPIES PERMIT VALUATION << I.5JOt:O.oO PLOT PLAN 0 TYPE OF CONSTRUCTION: (j) III IV V Occupancy Group A i E I H R M Division 1 "3 4 ~eq. (ps;' Check if Deferred Amount Brought Forward .................. $ Park Support Fee ........................... $ SAC ......................................... $ Collective Street Fee ....................... $ SewerTap ................................... $ License Check Fee ......................... $ Pressure Reducer .......................... $ Meter Horn ................................... $ Water Meter ................................. $ Sewer & Water Connection Fee ........... $ Water Tower Fee ........................... $ 2Sq. t- '> City: Permit Fee................................... $ 11/.00 Ill.'> 7.)"() Plan Checking Fee ......................... $ State Surcharge ............................. $ Penalty ....................................... $ Septic System ............................... $ Other ......................................... $ Subtotal............................... $ o o Permit When qProved, Date 11- -q ~ . Issued This is to certify that the request in the above application and accompanying documents is in accordance w~h the City Zoning Ordinance and may proceed as [ signed By the City Planner consl~utes a temporary Certificale of Zoning compliance and allows construction to commence, Before occupancy, a Certificate 01 City Planner Date Special Conditions ij any 24 Hour notice for all inspections 447-4230 9:00a,m, '10:00 a,m, 4Lf -J;;Z1-