1992, 09-11 Permit App: 92007514 ReroofINFORMATION WORKSHEET ru�
. .�
PARCEL NUMBER:
STREET ADDRESS:
CITY/STATS/ZIP: c �'
SUBDIVISION:
. -BLOCX:.. IAT: ZONE:__, DISTRICT:
LOT ARIA: ' ... : - F/A: WIDTH: DEPTH: R/W.:
# OF BUILDINGS:- # OF DWSLI,INGS: WATER, DISTRICT:
OWNER: PHONE: — I` 3
MAILING ADDRESS : l D L /7-7
CITY/STATE/ZIP:� (�
CONTACT: - PHONE - —
SETBACKS: — FRONT :..- • LEFT: RIGHT: .'..REAR:
PERMIT USE:
.-BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER:
_ l
CONTRACTOR: ,A L c(� , PHONE:c�-
MAILING ADDRESS:
ARCHITECT/ENGIZIEER: PHONE v - — —
MAILING ADDRESS:
NEW: REMODEL: ADDITION: CHANGE OF USE:
DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES:
BUILDING DIMENSIONS: X
(WIDTH X DEPTH) SQ. FT.:
REQUIRED PARKING: # HANDICAP: SEWER (Y/N): HYDRANT:
-IN DICE RECAP AND DISBURSEMENT VOUCHER
PAY TO .Qe
STORE NO. V— -79
STOREjQFfC�.
No. 780427
DATE 9-1— 9c;`
CUSTOMER'S NAME
SALESCHECK
NUMBER
JOB I.D. NO. OR
WORK ORDER R
AMOUNT
DUE
CONTRACTOR
ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE
ACCOUNT
NUMBER
DIV.
NO.
ADJUSTMENT
ACCT.
ACCT.
CONTRACTOR
EXPENSE
MEMO
SELLING
I certify that the installations listed above have all been
completed satisfactorily in accordance with the speci
fications furnished me.
(CONTRACTOR'S SIGNATURE)
TOTAL
AMOUNT . �"' TOTALS
OK TO PAY
CHECK NO.
14489 (See Bul. 0-187 Part 11 Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT
(AUTHORIZED SIGNATURE)
(DATE)
PAYING UNIT NO.L/07Y
PAYING
UNIT NAME
(ff Different)