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1992, 04-01 Permit App 92001119Vfs��64vws 8-.� PARCEL NUMBER: 9-1117 (01 L 3P INFORMATION WORXSHEET STREET ADDRESS: % �P (2 CITY/STATE/ZIP :v�� SUBDIVISION: - BLOCK:.. • • = - • LOT: • ZONE: DISTRICT: •Win: ' — DEPTH: R/W: # OF BUILDINGS:• OWNER: l i 4..7 . # OF DWELLINGS:- .WATER'DISTRICT: PHONE: 5 6' 9— �a— 997 � MAILING ADDRESS: CITY/STATE/ZIP:_ ,' — -a-44 (2 (/ 9 Cam% / — CONTACT: - PHONE - SETBACKS : — FRONT: . . LEFT • RIGHT: . - REAR: PERMIT USE: (26LOu a4e-A--)-1 ************!r*****ir*akaY*atatye*dc*lrle*ie*********#*ie*kakic*air#****at#******dedr******** .-BUILDING INFORMATION CONTRACTOR LICENSE NUMBER: - — Ste CONTRACTOR: ��r � l X `! ire%/ _r Q PHONE: 5 (.9 - - / / %CJ MAILING ADDRESS : ,')� () ( �7 -i n % ) - �( .o ( (J (7_ 0( ARCffiTECT/ENGINEER: PHONE : , - MAILING ADDRESS: NEW: REMODEL: ) ADDITION: CHANGE OF USE: DWELL UNITS: OCCUPANT LOAD: BUILDING DIMENSIONS: REQUIRED PARKING: BUILDING HGT: STORIES: X (WIDTH X DEPTH) SQ. FT.: # HANDICAP: SEWER (Y/N): HYDRANT: PAY T((�� l/[ / fiJ,4(J� n �/I n nit NGE RECAP AND DIS{3URSENIEN i VOUCHER CUSTOMER'S NAME Cf12_ -) e� I certify that the installations listed above have all been completed satisfactorily in accordance with the speci fications furnished me. (CONTRACTOR'S SIGNATURE) STORE NO. si" 0 X? DATE _Z J A OUNT ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE DUE ACCOUNT DIV. CONTRACTOR MEMO CONTRACTOR NUMBER NO. ADJUSTMENT ACC f ACCT EXPENSE SELLING 2 ialaq TOTALS OK TO PAY PAYING UNIT NO. (AUTHORIZED SIGNATURE) C/ CHECK NO. :- d PAYING NAME (DATE) (If Different) No. 463535 ov_ 14489 (See Bul. 0-187 Part II Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT CONTRACTOR'S BILLING COPY