1992, 09-11 Permit App: 92007516 Reroof 13024
INFORMATION WORKSHEET .
•
PARCEL NUMBER: J /,
STREET ADDRESS: /c
CITY/STATE/ZIP: ) l _ '7 qa/oq
SUBDIVISION:
BLACK:. . . LOT: ZONE:__- DISTRICT:
LOT AREA:- - F/A: WIDTH: - DEPTH: R/W.:
# OF BUILDINGS: . # OF DWELLINGS: .WATER'DISTRICT:
OWNER: (-11/10 b ii irc PHONE: - -
I0.ILSNG ADDRESS: / a ()6d15
CITY/STATE/ZIP: j40 / / 12. 090 qqca /02
CONTACT: - PHONE:: - -
SETBACKS: - FRONT: -- LEFT: RIGHT: _ REAR:
PERMIT USE: Pi 414 1 / Y� (�' 44Y19-'1
BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER: 5 - /4/2 - 6e - 3-49- ft.)
CONTRACTOR: , / I V L PHONE: •73 - 4 2- gS
MAILING ADDRESS: (2=)A %3 -227-.7 4z,59.4 ,7 /
&
ARCHITECT/ENGINEER: PHONE:- - • - -
MAILING ADDRESS:
NEW: REMODEL: v 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:
/f h / INOICE RECAP AND DISBURSEMENT VOUCHER
PAY TOjekkazttyLii• 6f��7-(igc, Y(.t" . iiid:,: S -
No. 780419
•
STORE NO. V027
STORE474.0‘,-"ce_ DATE • - - --
i
AMOUNT ALLOCATION OF EXPENSE—FOR INSTALLATION OFFICE USE
CUSTOMER'S NAME SALESCHECK JOB I.D.NO. DUE ACCOUNT DIV. CONTRACTOR MEMO
NUMBER I WORK ORDER NO. CONTRACTOR NUMBER NO. ADJUSTMENT ACCT. ACCT. EXPENSE SELLING
I q G
Way �� 11`42g3-705 68.
c /435_ &, , of
/.0qa. i). ailia. •
' k.6
I_____Ill_I I
1 1
1
-i_
�� �
I certify that the installations listed above have all been TOTAL c:2--
completed satisfactorily in accordance with the speci AMOUNT / �.�- TOTALS , 63,/fications furnished me. E
OK TO PAY _ PAYING UNIT NO.-44119—
(AUTHORIZED SIGNATURE)
PAYING
CHECK NO. _ — UNIT NAME
(CONTRACTOR'S SIGNATURE) (DATE) (If Different)
14489(See Bul.0-187 Part II Supp.8) REV.3/91 SEARS FORMS MANAGEMENT
ACCOUNTING COPY