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1992, 07-17 Permit App 92005421 Re-RoofPARCEL NUMBER: a2- 51-IZA gsiz FORMATION WORXSHEET STREET ADDRESS: I / %() 4e If i?�2�9 X.-PJy • CITY/STATE/ZIP : Gll.4A .e ,,{ WO f _ 6/9 o1© (c SUBDIVISION: : BLOCR:. • ..= • _ • LOT: ZONE: - --DISTRICT: LOT . F/A: WIDTH: DEPTH: # OF BUILDINGS : • . # OF DWELLINGS:. . RATER • DISTRICT : OWNER: 73ELILING ADDRESS: CITY/STATE/ZIP: CONTACT: PHONE: �2i ! % � �'-3c�c9-/ 0.nm,4 161 Gera - q 9 a-i PHONE: SETBACXS: — FRONT:.--. LEFT: RIGHT - PERMIT USE: /2Q , **************************************************-************************** .•BUILDING =FORMATION CONTRACTOR LICENSE NUMBER: CONTRACTOR: MAILING ADDRESS: ARCHITECT/ENGINEER- MAILING ADDRESS: Ste- /2- 3 i AO1)Q PHONE: — (p Po 3-2/27 9 99z1 PHONE : ' - NEW: REMODEL: < _ADDITION: CHANGE OF USE: DWELL IINITS: OCCUPANT LOAD: BUILDING DI2ENSIONS: REQUIRED PARKING: BUILDING HGT: STORIES: X (WIDTH X DEPTH) SQ. FT.: * HANDICAP: SEWER (Y/N): HYDRANT: PAY TO INV ICE RECAP AND DISBURSEMENT VOUCHER STORE NO `'I n9 STOREN2 No. 780678 DATE / CUSTOMER'S NAME SALESCHECK NUMBER JOB I.D. NO. OR WORK ORDER NO. AMOUNT ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE DUE CONTRACTOR ACCOUNT NUMBER DIV. NO. ADJUSTMENT ACCT. ACCT. CONTRACTOR EXPENSE MEMO SELLING (-16A_ �� �y� og 4' a 3gol % 64' z Po gox 7 Li i(oo.s-- an salv/u-4(AIR- 990/ �y I l it ME I certify that the installations listed above have all been completed satisfactorily in accordance with the speci fications furnished me. TOTAL AMOUNT / ay ZZ TOTALS LQry OK TO PAY PAYING UNIT NO �% Q 7 �/ (AUTHORIZED SIGNATURE) CHECK NO (CONTRACTOR'S SIGNATURE) (DATE) PAYING UNIT NAME (If Different) 14489(See 8u1. 0-187 Part II Stipp. 8) REV. 3/91 SEARS FORMS MANAGEMENT ACCOUNTING COPY