1992, 05-01 Permit App: 92003021 Reroof g55LN otli q2 - 3o2(
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INFORMATION WORKSHEET � O
4
PARCEL NUMBER:
STREET ADDRESS: /7V// ,
CITY/STATE/ZIP: 4/. /, 1, 10!. 40
SUBDIVISION:
BLOCK: _ . LOT: ZONE:_ DISTRICT:__
LOT AREA:-. -F/A. WIDTH:_ DEPTH: R/W:
# OF BUILDINGS: • # OF DWELLINGS: .WATER•DISTRICT:
OWNER: ( - - L-AV &_ _ PHONE: ; �` 9(9 >- 9 ?
ADDRESS
._: �, z
•I+DfILING �' / �~7 � e -
CITY/STATE/ZIP: J )- - -, ��2— L 9e 9 0-0
CONTACT:
PHONE:- _ _;
SETBACKS: - FRONT: .._• LEFT: RIGHT: •-- REAR:
PERMIT USE: Re__ ey /41&-C. L`}-Y1 <°a
****************************************************************************
BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER: ,
CONTRACTOR: 4. /16:2 PHONE: ' /./(?-?-///72
MAILING ADDRESS: G' ,v �/<<1��. ,�i / / At ZmI
ARCHITECT/ENGINEER.: - . PHONE: - • - -
MAILING ADDRESS:
NEW: REMODEL: ADDITION: CHANGE OF USE:
DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES:__
BUILDING DIMENSIONS: I (WIDTH I DEPTH) SQ. FT. :
REQUIRED PARKING: # HANDICAP: SEWER (Y/N) : HYDRANT:
/ ff, /'� 17 I DICE RECAP AND DISBURSEMENT VOUCHER
PAY TO 6(0u- rU�NW% � �/}�t.0 55
C � ���� No. 40335
STORE N`O.. /
STORE Vi Odle-A/1—e-- DATE 7 —2-3-'10
AMOUNT ALLOCATION OF EXPENSE—FOR INSTALLATION OFFICE USE
CUSTOMER'S NAME SALESCHECK JOB I.D.NO.OR DUE ACCOUNT DIV. CONTRACTOR MEMO
NUMBER WORK ORDER NO. CONTRACTOR NUMBER NO. ADJUSTMENT ACCT. ACCT. EXPENSE SELLING
,:1 114 sal. # CA-- , do r ,414 g.3�—
111 a a ).-)1 ci--tAA1 --�
4� .I
1
I I
:1 I. I�
I
"� rill
■ •
III
I certify that the installations listed above have all been TOTAL /O
completed satisfactorily in accordance with the speci AMOUNT 6?. 2-z I I TOTALS I (pD � 2
fications furnished me. �� L�2
K PAY PAYING UNIT NO.
7 �/ /U
(AUTHORIZED SIGNATUR )
1 CL1-- 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