1992, 11-30 Permit App: 92010441 ReroofSTREET ADDRESS:
CITY/STATE/ZIP:
SUBDIVIS1044--,
INFORj4ATION WORKSHEET
.�1D�� -2-7.
:BLOC$: LOT: ZONE: --DISTRICT:
LOT AREA: -F/A: WIDTH: DEPTH:_ R/W:
# OF BUILDINGS: • # OF DWELLINGS: WATER,DISTRICT:
r
OWNER: L. �J ! `W—` ( L/Y// ! CLQ [ PHONE: / 7_22Z7
MAILING ADDRESS:
CITY/STATE/ZIP:
CONTACT:
SETBACKS: - FRONT: -; LEFT:
PERMIT USE:
.BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER:
PARKING:
# HANDICAP:
SEWER
CONTRA CTOR�i�
HYDRANT:
PHONE:
_......, ... .,.�w-ate-.>-..,«:.... __.,...,«,
MAILING ADDRESS:
ARCHITECT/ENGINEER:
PHONE:
MAILING ADDRESS:
NEW: REMODEL:ADDITION: CHANGE OF USE:
DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES:
BUILDING DIMENSIONS: S
(WIDTH % DEPTH) SQ. FT.:
REQUIRED
PARKING:
# HANDICAP:
SEWER
(Y/N):
HYDRANT:
_......, ... .,.�w-ate-.>-..,«:.... __.,...,«,
.._...,.. ..�.,........:.Z,.-.. s
.:.. .�- r'�.' z.,".'
__ _
• v
.o.,��4,�,
PAY TO
A
STORE NO.
STORE, rea4Cl_
No. 742549
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
lO
�
I certlty tnat the Installations listed above nave all been
completed satisfactorily in accordance with the speci
fications furnished me.
7
(CONTRACTOR'S SIGNATURE)
TOTAL
AMOUNT
OK TO PAY
CHECK NO.
TOTALS
(AUTHORIZED SIGNATURE)
(DATE)
14489 (See Bul. 0-187 Part II Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT
ACCOUNTING COPY
PAYING UNIT NO.
PAYING
UNIT NAME
(lf Different)