Indiana E 12420 Shurgard Signage
(T Fi IS IS IV OT A PE R MIT) ' BUILDING PERM IT APPLICA.TIO.N WORK5HEET
PL.EASE PRIIUTAND C{]MPLETE C)NLY THiC7SE PARTS C7F THE FORM YOU UNDER5TANEl
COMPLETE ItV ffVK
(Please return M3 originaM and your buildfng plarrs to the i?eparlment of Builtling and Safety)
sHAaED ApEas ARE FOR aEPARrMErvT,aL usE
. Proiwt Humber'~C)57,~~ ~~3
Owrmer'e Nama LAST FIRS7 MI ,
Pro~eet AOdrwe (SRr98t f4ame d. Nurnber) Zfp
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Appltcsrrl Address
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c Ety State zip Phone
ausinws Phons
5410~~.
Qntrwiar r Agent Ada res#
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Business Phpne
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Lender ACJdress
64#y State Zip Phone
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Nun'abor [rf L)welliiV lPnits l+lumlw Of Buildings , LAI Size (Sq, F!.lJ4"s) DBpth FronlaQs
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Front Setbe* . Left Setbac* Rlqltit 5ettwk , y POW 3etback
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Additk" intixnnstic3n . . - . . . square Faata4a
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DEPARTMENTAL REVIEW
Cond. Approved Approval Hold
Envlronmental Hoalth Application N
❑ W. 1101 Collefle •
Room 200
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41annlnq/2onlng . N. 721 Jefferaon
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~ N. 811 Jefferoon
Utllltiss
❑ N. 811 Jefferoon
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~ Plan Rwlew/ Flre Pnventlon
N. 811 Jefferson _
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Other (SEPA/Critiaal Material/afc.)
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~ Fasf Track/Speclal Inspsction Informatlon
PnoJect Representative Phone
Address
I certlfy that I have examined thia application and atate that the information contained in it and submitted
by me or my agent to compile aatd applicatlon is true and correct.
Signature Date
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