1984, 11-14 Permit App: 00003346 Repair Fire Damage ` BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
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1 Owner's Name (last) (first) (m) Department Use Only
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2 Project i,ddress(not Mailing Address)a Road ame Space Zip
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3 CityI1munity State Subdivision/Plat Name
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