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1992, 11-16 Permit App: 92010443 ReroofPARCEL HUMBER: INFORMATION WORKSHEET dk2:-. 114 3 STREET ADDRESS: 979 ci CITY/STATE/ZIP: SUBDIVISIOZ5. - .- - BLOCS:: -- LOT: --' ZONE: - DISTRICT: LOT AREA• 'F/A: WIDTH: DEPTH: R/W: # OF BUILDINGS:_ OWNER: :rl/-0YtC� # OF DWELLINGS: MAILING ADDRESS: CITY/STATE/ZIP:- CONTACT: 9/9 WATER DISTRICT: PHONE: SETBACKS: - FRONT: PERMIT USE: LEFT: PHONE• RIGHT: - "TREAR: *******************************************************,*4******a**ae******** _BUILDING INFORMATION CONTRACTOR LICENSE NUMBER: -- CONTRACTOR: )4?4&4.9-/ ,Og-"Lcp MAILING ADDRESS: (2394 -3:7F)7 ARCHITECT/ENGINEER: MAILING ADDRESS: PHONE: -7 7A-`S(c3 /th17?2d PHONE NEW: REMODEL: j< ADDITION: CHANGE OF USE: DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES: BUILDING .DIMENSIONS: - • REQUIRED4PARKING: # HANDICAP: SEWER (Y/N): `,HYDRANT:".:.; A i 1 "-�- divh,�eSU'7i:5=p.!'•?-.d%y F..G"� L'.Sa�;S.?�a^3-z;-s.�:-yr.. k:i: .'.�'.:7.i PAY TO {„) INV CE RECAP AND DISBURSEMENT VOUCHER STORE NO.,C�—� No. 742592 DATE //'-' CUSTOMER'S NAME SALESCHECK NUMBER. JOB I.D. NO OR WORK ORDER NO. ' AMOUNT DUE CONTRACTOR ALLOCATION OF EXPENSE -.FOR INSTALLATION OFFICE USE .ACCOUNT NUMBER DIV. NO. ADJUSTMENT ACCT. ACCT. - CONTRACTOR EXPENSE MEMO SELLING //-75. 2W 4'3 � f7 ' 0/ • -tri ' - • -Pbk)27-2,—L' . I certify that the installations listed above have all been • completed satisfactorily in accordance with the speci fications furnished me. (CONTRACTOR'S SIGNATURE) 14489 (See Bul 0-187 Part II Supp. 8) REV 3791 SEARS' FORMS'MANAGEMENT TOTALS • (AUTHORIZED SIGNATURE) (DATE) . • ACCOUNTING COPY' PAYING UNIT NO (41/7 PAYING UNIT NAME (1! Different) _ . .