23B-015 IV. IDENTIFICATION — To be completed by all applicants
Name Mailing address — Number, street, city, and State ZIP code Tel. No.
NOTES and Data — (For department use) Al / �J� �J ry / /y
Ow ner or J I U' �� Ei i 4� ttr /4 l rie 6;7- 0 S.-/ �J 1 06 `� CS CL-'
Lessee
_J. N 374 L L_ L& ooca b� � e i, , ,� S rGo Ap 1 � � � 1�- ✓� l �? 7
�� ?�'�!� Bui Ider's
L. License No.
V i G� G �j� J B - et Contractor
c 4S �C � C L r ?Pt rl� 7u�! �'1r�, i� - �p�F i.v4 "��
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.
Signature of applicant Address
Application date
P P
/ /,' S 7 `7
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
Fee Started Approved
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Date Date
Permit or Approval Check Obtained Number By Permit or Approval Check Obtai ed 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 FOR DEPARTMENT USE ONLY
Permit number 6 V 3
Building Use Group
Permit issued , /t�� 19 7 , 49_
Building
Fire Grading
Permit Fee $ Pr/ C ?C" Live Loading
Certificate of Occupancy $ Occupancy Load
Approved by:
Drain Tile
Plan Review Fee
ITLE�