16A-20 (2) t
IV. IDENTIFICATION - To be completed by all applicants
Name Mailing address — Number, street, city, and State ZIP code Tel. No.
'� e ' / f4. � 75R , 7
O NOTES and Data - (For department use)
tC cde'r'* T T Y' ,S7)� f"t�� t.. e k 1/ 2 • /Az
Owner or
Lessee file 1"/C)-5-.3
Ir n c J" r'� 5' m
Builder's
2.
License No.
Contractor
3.
Architect or
Engineer
1 hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to
make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction.
Si r nature of applicant Address _ (� / - �`�� s Application dote
C � T dr n e /os-3 �� #. . iy. 9
DO NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD - For office use
Plans Review Required Check Plan Review Date Plans By Date Plans By Notes
q Fee Started y Approved y
BUILDING $
PLUMBING $
MECHANICAL $
ELECTRICAL $
OTHER $
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Dote Permit or Approval Check Obtained Number By Permit or Approval Check Obtained Number By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building Si FOR DEPARTMENT USE ONLY
/
Permit number t
Building Use Group
Permit issued I 19
Building pp Fire Grading
Permit Fee $ Live Loading
Certificate of Occupancy $ Occupancy Load
Appro t.ed. by:
Drain Tile $ r -
Plan Review Fee $ -...„ , ____
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