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J R H ~ 2~-- 9 4 F ~ I 1F=- = :1. 0 ¢ T T ¥ OF RU Eo R A P . 0 2 <br /> <br /> Applc~on; J "21420 Mai~ St, ' PHONE <br /> <br /> RESIDENT~A~ ' : ~ COMMERCIAL 0 New ~~ ; ~ <br /> I~ Addillon .~ Rc4oc,,tion .] O Addition O Sign -. ~ <br /> <br /> gAccessow · ~ )t~ _.~¢ ~,.J OChangeofOccu~ncy ~Oher <br /> <br /> ~;~'S*~'-~r'~af~*,r';,.~ I N~, Stories: J Occupant Load Or Number of Employees: <br /> "~ [ar~'~; '~ ~ . . Ma n F ocr' ~ Second F ocr' Garage Heir:t-, <br /> <br />2, Location ~f Installation <br /> <br /> Section: .~ ' fo'.~.nshlp: ' Range: ~ Zone Map ~ Set Bauk: ~:,'(:r t <br /> <br /> Lo w d h '; , Depth Acres: J Irreg. Lot; J Corner: Side ~. Back <br /> <br /> Wa~er Meter Size,'. .................... [ Ty~ Ba~ Flow: <br /> <br />3, Contraqt¢~ Information <br /> <br />Jl~l own, reside Ir:, ?: ,.,d, (,side in the c~mplet¢ ~tructure. <br />la undersand~ha:( i.~:~tmgistera~ac~n~trucb~nc~ntr~ct~rifthestructureis~d~r~eredf~rsaiebef~re~ru~n~p~et~n. <br /> <br /> I ,V!~ hko only su~n~ractor$ ~gisier~d with the Const~ctlon Oonlractor'¢ ~ard. If I change <br /> Con~raCt with a cBnka( k? wl,o is registere~h the Co%~ction ConkactoSs Board, a~ will tmmSately P0~ ¢i~ 9¢~r~r~ 0~th~ ~9 o[~]~ ~r ~ct~r: <br /> <br /> Mailing AddresS: <br /> Q [ am a regiSler~;.<J !',,~il~-.~;,r ~)R the authorized representative of a reglsterecl builder. <br /> Archilect nsme: <br /> <br /> Mailing AddresS: <br /> <br />4. Fee Schecft¢':e <br />F~^t IAT ON Se,'-%i f~tage <br /> .,h ,;, ;on Schedule' o de ermine valuation bas~ on square <br /> <br />Permit Fee <br />Msnufactured <br />Mechanical <br />Plumblng <br /> <br />Phone. , . . . .. <br /> <br />State Surcharge . .: ~ ,)~, 1~ .... <br />Plan Check . ;~. ~' ~ .... <br />System Oev. <br /> <br />Water Meter <br />Water Connection = ._.~ _~.~__~ <br /> <br /> information is correct and that I have read and understand the Information Nolice to Property O.x,f ~,:,,'..~. about <br />On the reverse side of this form. <br /> <br /> ...... ..-,: % ..: ;~ <br /> <br /> <br />