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N °_ 3823
PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC ❑ PLBG Al SIGN ❑ ZONING FLOOD PLAIN HEIGHT
ADDRESS Ho?' / Mon AN:, )
/►� `'� PLAN NO.
OWNER Ch A.64 71 aA1 }}ma frt
DESIGNER
USE /NATURE OF WORK }.1 .elf, 0,Atid . % a7 u 1
BUILDING CONTRACTOR
Size Sq. Ft. # Rooms # Stories Height
Foundation Class of Const. Occupancy Permit
HEATING CONTRACTOR
Heat ❑ A/C ❑ Vent ❑ Fuel /System Heat Loss BTU'S
ELECTRIC CONTRACTOR
Electric Serv. New ❑ Change ❑ Temp ❑ Type Volts Amps
Fixtures Switches Receptacles Circuits
PLUMBING CONTRACTOR Wa. 9mzi',_4 &'t
BT / WH Disp _ WSoft _ CBasin //
Lav Sh DW DF San. Sewer
— WC FDr SP Ur Storm Sewer
— Sink LTub Eject SS Water
Other
°O Park Dedication $
/
FEES: Valuation $ .71i 5. P ermit Fee Paid $ / O•
ISSUED BY / []
Date ��,�/ 7 14 Final /O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE `llyA kt i MK- ti.1).11 t._Y• 04
AGENT /OWNER
DATE
ADDRESS
TELEPHONE # •