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10D-030 (10) ., IV. IDENTIFICATION — To be completed by all applicants Name Mailing d• ss — X mher,e city, and State ZIP code Tel. No. 1. �� '�'� a :___ G.¢ O -- i rco 6 17 NOTES and Data — (For department use) Owner , s ` 7 Builder's v 2. — L tense No. Contractor g . . ilk 0151Z4 A ( / 1 & 3. Arc or ' � , �� ^> 1� �i� ��"- • , J.W iti 2),..i Engineer ' t� I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to A C. 3 mak this application as his authorized agent and we ag ee to conform to all applicable laws of this jurisdiction. S re of applicant f Addre Applicat date -D—cer ssr� A- C1°' 4 DO NOT WRITE BELOW THIS LINE V. PLAN REVIEW RECORD — For office use Plan Review Date Plans Date Plans Review Required Check Fee S tarted B y Approved By Notes F / BUILDING $ Co PLUMBING A MECHANICAL $ A (-- D 7 r / g LO ELECTRICAL $ T A / 0 OTHER $ E } 1 VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS ,4 E / . Permit or Approval Check Obt t ne Number By Permit or Approval Check Obtained Number By —D 13 BOILER PLUMBING CURB OR SIDEWALK CUT ROOFING bER 1 ELEVATOR SEWER _ ELECTRICAL SIGN OR BILLBOARD FURNACE STREET GRADES GRADING USE OF PUBLIC AREAS OIL BURNER WRECKING OTHER OTHER VII. VALIDATION Building FOR DEPARTMENT USE ONLY Permit number • Building. (`, 7 U se G rou p Permit issued , 196 Bui Iding Fire Grading Permit Fee $ � Live Loading Certificate of Occupancy $ Occupanc Load Approv by: 9 e-s, J „,„ . . Drain Tile $ Plan Review Fee $ TITLE "el 111 d SL1100.11.0og oLJJ Lb 50A 9b jo JagwnN .� I f. S y 0 � 1 6E ai.i.• : a•aii:: ::1::l muini...wl z J + i i:iii _::lsz � l` II ^d �JOyonaia u0 aq aJa44 II!M ,C z -dd — Ja y • r s • • .. •..e .. : .. • ■ {{ �* - p pi qp ■■ : :. .�• p p fi r. p . : ' . 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