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1992, 03-18 Permit App: 92001636 Reroof 53-o Lit/t/ Qt-is 0 INFORMATION WORKSHEET ( )eI (Q S5 PARCEL NUMBER: STREET ADDRESS: 6 -- 9 CITY/STATE/ZIP: ,moi ,` ,/ • SUBDIVISION: . . BLOCX:.. LOT: ZONE: - DISTRICT: LOT AREA: F/A: DEPTH: WIDTH: R/W: OF BUILDINGS: . # OF DWELLINGS: .WATER'DISTRICT: OWNER: 1 61.e_ J PHONE: - - MAILING ADDRESS: 3 °- 1-CITY/STATE/ZIP: 'te�GZ L��� CONTACT: PHONE:- - - SETBACKS: - FRONT: .... . LEFT: RIGHT: • ~. REAR: PERMIT USE: ( ( ,r( _ L/d1. Gl aA/9--'l a ,5 6/' O� tk***************************************air********11e************************** BUILDING INFORMATION CONTRACTOR LICENSE NUMBER: S - - .3 7) /C) CONTRACTOR: PHONE: 3-65% 70 MAILING ADDRESS: P(,) , 3'79`/ .& �� � 7/1g, 9 ARCHITECT/ENGINEER: PHONE:, - • - - 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:__ I / / /// VOICE RECAP AND DISBURSEMENT VOUCHER PAY TO i 1� " -i-c-2. L Cl(- LE'C �✓Z No. 463574 STORE NO. 127.__ STORE J r DATE 3 /� 9� AMOUNT ALLOCATION OF EXPENSE—FOR INSTALLATION OFFICE USE CUSTOMER'S NAME SALESCHECK JOB I.D.NO. DUE NUMBER WORK ORDER NO. ACCOUNT DIV. CONTRACTOR MEMO CONTRACTOR NUMBER NO. ADJUSTMENT ACCT. ACCT. EXPENSE SELLING B i ..��_ °��'(197` *7, -a--- /�36 3,/ �t zz /�.,V -- &_ s S 9 A i I certify that the installations listed above have all been TOTAL � /� ` `�� completed satisfactorily in accordance with the speci AMOUNT r - TOTALS 2 /`/ fications furnished me. OK TO PAY PAYING UNIT NO. 5//) (AUTHORIZED SIGNATU ) 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