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Trent E 12119 Interior Partition Walls i~ y l~ r- (THIS IS NOT A PEFiMIT) ; BUILDING PERMIT APPLICATION WORKSHEET PLEASE'PRINT ANO, COMPLETE ONLY THOSE PARTS OF THE FORM YOD UNOERSTAND ~ COMPLE7E IN INK (Pleasp retur n triis oriyifyal and your buildmg'pidns to,the Department,ol Bullding and Sateiyl SHADED AREAS ARE FOR,OEPARTMENTAL USE + PIniLvt NuntO@r Owner o NWm I.AS T FIR5T MI . ,~OLF - - _N.iG ~ _ _ _ _ Q • _ _ - - P/vltx:t Addrms ISiree► Nanie 8 Nur►iper I rIP 9 e. T~t1FArT S~IrA~E tq/~ 9'~~ AOpl►c4M Adqr~s - - 4/O4F p✓ic ae /xoi ✓A4-vJT' RO. C~ty ^ State 2ill Ph„iW ~ _ ~..f~~~✓~ - -w''~~ (iu~rr1~ ti o. Ph9R@ ! S01 ► 724 ~ 3,1 7,W ; Conl►ACiQr 1Agent A~~ret;!'' -Siaie ~ ZIp Pnnnn 1 1 ~ Conlact License NumDar (Repulr i) 8usiness Ptwne Aren ttoeet ldErtgmaer Addrasa City State - Zip Phone f t ConIDCI Bus►ness Phane Lerlder Add►ess Gcy ok` st e zip ~ i ( i oasorlbeworR ` ° R aes Comm~. , ~'M r~r_ T~o N(.-l1 A LL S " • SuodivWonlPaetNarna/Shsrt Wet Numbet ~k'~4N0 ~Il~. C%R65/ /6T SL - - Y As=~ Pbrcel Number L.01 81odt Piat Number Fmtinon! FIle Nunsbero / ZonA~ Cw►►p Plan Certaua Trart 1+lweAm of OweIIMp Unlb tiumtief ot 8tiildlnpe Lro2 81n (64. FI./Aae) Depth: Fronlng Ftant $etbaiGk Letl Setbatlc - Right Selbedt ' RSar S8lbadt ( Addittona! Information SQua►e Fdotae ~ . ~ • . W . N ~ - 1- Z W ~ H Q - 4 a, w o~ ~.t,,' 7i~1, R~ U•x, Typd 13' 0 v 14 • DEPARTMENTAL REVIEVkI ApVrowed Cond Hqtd Apprawal Eavironmente! Heallh Pririnit Numk)rcr !90 4 Ir'11 1101 C4tlege wv. i Room 200 7 Rlbrt~i~ ~ ~ Planning/Zoning N 721 Jeflerson ~ . . 00- Engineera Perrnfl Number ~ N 811 Je! tersom Utrrltoes ~ N Bt 1 ,Perferson ,0,,Plan Revlew/Flre, Pt'ewenllon ~ AI 811 JeffeTSOn Dlher (SEPAICrilEcsl NiaterCailetc ~ F] ~ Fast TrecklSpecFsl Inspection #nfnrma#lon Prolect Aepreaantatwe Phvne AriciresS Iftr'tif~ that i f1ave exdmint:11 inis aCm►w„'tF~~n and sldtt• triaC tne intorinatson containrd in it and submitled tj} rirE, or my apent is true +torrvct, tegal ~iio blnding . ~ rAr c?! ~ %,q4 rs 1l, a, ~1.A'.,, (r~l ~ q• I~d t C 1 ~ f I