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1992, 03-05 Permit App: 92001447 ReroofPARCEL NUMBER: �4 3y.-r�CS ycSo BS INFORMATION WORKSHEET STREET ADDRESS: /7// YJ , k-GLGcz • /CLQ - CITY/STATE/ZIP: X LpSt P. , // w, % 906 SUBDIVISION: BLOCK: LOT: ZONE: --`DISTRICT: LOT AREA:- _ F/A: WIDTH: DEPTH: R/W: # 08 BUILDINGS:• # OF DWELLINGS- WATER DISTRICT: OWNER: /.l a iptgehee-;(_, PHONE: 5-69 — 1„2 95— / 7// S/-7// CITY/STATE/ZIP: �e ca,"/p, /at ///Qr0/� 37/40-1/-e0 /118; gz(V CONTACT: - - PHONE:- - - SETBACKS: - FRONT:.-. LEFT: RIGHT: . - REAR: PERMIT USE: ,'t 66- 3/4hI d "16-21 .69,39.`g :BUILDING INFORMATION CONTRACTOR LICENSE NUMBER: 3' E - 4/e - - 3-74:9_4,7/ CONTRACTOR: 0' MAILING ADDRESS: po A :37011 PHONE: 5D9 - L / -//70 ARCHITECT/ENGINEER: PHONE: MAILING ADDRESS: NEW: REMODEL: / ADDITION: CHANGE OF USE: Alm .1.11 DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES: BUILDING DIMENSIONS: % (WIDTH % DEPTH) SQ. FT.: REQUIRED PARKING: # HANDICAP: SEWER (Y/N): HYDRANT: PAY TO�/U INVOICE RECAP AND DISBURSEMENT VOUCHER CUSTOMER'S NAME', ' SALESCHECK NUMBER .STORE NO 41�%� STORE JOB I.D. NO. OR WORK ORDER NO. No. 463556 DATE __- g.7 AMOUNT DUE CONTRACTOR ACCOUNT DIV. NUMBER NO. ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE CONTRACTOR EXPENSE MEMO SELLING c? —cg '7 ove*I mi /CJS 17 421) 040GS' ,Cod C PQeo>< I35DI (99,/ E�. ehmq 1 certi y that the installations listed above have all been completed satisfactorily in accordance with the speci fications furnished me. (CONTRACTOR'S SIGNATURE) TOTAL AMOUNT OK TO PAY TOTALS (AUTHORIZED SIGNATURE) CHECK NO. 1/1489 (See Bul 0-187 Part II Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT l� j (A E)� CONTRACTOR'S BILLING COPY PAYING UNIT NO. '17n2 PAYING UNIT NAME (If Different)