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Trent E 10619 Caretakers Mobile ~ (THIS IS NOT A PERM1T) ~ BUILDINGi, PERMIT APPLICATlON WORKSHEET ~ PLEASE PRtNT AiVD CaMPLETE ONLY TH~OSE PARTS OF THE FORM YOD UNDERSTANb COti1PlETt iN INK (Pleass rtturn this original and yoiur, bUilding p{a~'~`to Ehe Oepanment,~of Butldtng and Satety) SHADEO AAEAS ARE FOR dEf'Af{TMENTAI USE OrvnW's katm - LAST - 10W MI . e ~e,~ ~.p c y ~ -t~rdjeet Atltic~s~St~esi NameA Numbe~l Zi0 -nl~ T- • 1 ~ a f~ 'APPIketMt AdOl-am ' 'Cilit Ssale Zio ~✓~ty cj'J 5~ G ro ~ ~ .~06 K a- ou -p- .4 s eus~rtes~ Ph~ne` i 1 C~ieltracimJA~en1 - - Addriess i ~ atoy - state ~ 2io - pf+a,e c i co+»a¢f ^ 1lmme Nijt^1er cRLa,uTNdf au~)~ess ahone 4 ~ Atchitecl (EOgineat A, ddress City ZiQ -Phorte I ~ t ) $IJSIf1CSSph0118 LQ'fld@t A&lteS il dfy St~te - ~ ZfD` Phone ~ l 1 , [7osaclbe Wask , , ~ ~y, - Ras• ~ COrr►m/ r ' SuDdiftbnl,Fqat "el 1 NumQer o ~ ; ~ ~ . Aesamor Peroel Ntimb& f 4v1 81odc ~ Piai Numter L1 G~~l~" ~ " ~►~2 t ~'l ~ ~ partinent fite Numbro - Zm9 Oomp. Wen Cefts=Tmt Ntt}rObW Of DwO`Ire0l;Mits Number,of Bulldings fttAcre) Ibpth Fra+tsps Front sqloadt ' Wt setbck Algri setbitk atwv+r+dth Addrr(«+a~,~Ator,mat~o~ ~ , 1 svuare`wclass - 2 ~ O Q _ g aC . p - u6 z _ z - - ~ O J ap r{WraW 01 60dtOdttl3 Buildirtp Toth " Daf9 GiOup _ rTYPe . OEPARTMENTAL aE1/IEW r,• ApproVed Ap ~ Hold f Envtronmentsi Heelth AppHcatlon N d w 1101 coueAe ' Raom 200, ~ . ~ Plenning,/Zoning u N 721 Jetfersan , Y ■ ' Engineers ~ ~ N 811 Jeifer`son, • - - Utlllfiet ❑ N.811.18fterson Plen Revtew/Five Pravenllon ❑ M. 811 Jetfemn Other (SEPA/Crlttcat Msteriat/etc ) ❑ - ~ }Q Fas1 Trsek/Speclal Inepecilon IntormeUon ti Pro]ect Reprosentative Phone Address 1 certify that 1 have examfned this application and .4tate tl►af the `iniormation contairted 1A it°ahU subrnitted by,me or rp , y ageht to compiie said-application is true and carreci . ~ Sigwure Date ire c_:;) a 1r► r~ v ~ ~ 76' 0 / ~ A,q i ° fk A ~ /V ~ ~ ° _~.~v~ dW e , ~ s► ~ ♦ ~ / ~ ~ • t ~ ~ ' ~ ~ tjr ~ ~ ~1 ~ 51, ~ _ 3 , ~z ` ,~,~'d` ~ 3 ~ i ~ ' ~ ~ ~ • '~'1 ~ ~ ' ~ ~ ~ ~ ~ . ~ ~+j ~ ` ~ tl ~ ~ , ~ ~ 1~ ~ rJ ~ 6, ~ ~ _ ` , r•__ oq t ~ ~ _ •••-~-j-~ J ~ . ~ ,