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(THIS tS NOT A PERMIT)
(BU1LDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COPr/IPLETE ONLY THOSE PARTS OF TFiE FORM YOD UNDERSTAND
COMPLETE IN INK
(Piease return thts arigina) and your building plans ta the Department of 8uilding and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE ~W N~ ~
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Environmental Health Applicadon,11
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ProleaRepregentative PAone
Ad"Cress
I certify that 1 have examined this application and state that the informatton contained in it and submitled
by me or my agent to compils eaid appflcatlon is true and carrect
~ Signature - - - Date