Sprague E 12012 Poliquin - Pole
~ (THIS IS NOT A PERM IT)
BUILDING PERMIT APPLICATIOH WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS O.F THE FORM YOD UNDERSTAND
COMPLETE IN INK
(Please return thls original and your bulldtng plans to the Department of 8uilding and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
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DEPARTMEAITAL REVIEW
Approved App~e1 Nofd
_ Emrtronnantal HeaIlh Appllcatlon,d
❑ W.1101 College
Room'200 ~ Plan~ing/Zoning - - - -
FN721 JeHerson
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N. 811 Jefferson . uumles
❑ N. 811 Jefferson
~ Pimn RevlswlFlre Prsvenllon
N. 811 JeHerson .
Other (SEPA/CrItkel MatsMal/ete.)
❑ ~ ~ ~ ~ -
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prpjec;t Representetive Phone
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Address
I oert(fy that 1 have examlrted thie applicatlon and stete that the information contained In Wand submitted
by mo or my agent to c.ompfle',sald appHcation Is true end correct
Signature Date - °
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