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<br /> "5335�8�'Street,ZephyrhiNs,'F!33542
<br /> Teiephone.813.780A000 Fax 813:780.0005�
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<br />; ':PRQ�ECT .30B:SITE: -PROPERTY'flWNER
<br /> Address: 3 " �'� � c.c,� IVame: -t rs^i1�
<br /> Unft#: Acfdr�ss: Untt: -
<br /> Farcel Identification Number: Ci .State Zi �
<br /> !e� - -,� - �- 11�D- � Phone; Fax:
<br /> �CONTRACTQR:
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<br /> Name•
<br /> contractar�s ucense#. �s. � E-Malf: ud � 3,;�t�.c ' . r--
<br /> Phone: � -7 Csll• / Fax• --7 S -.5��
<br /> ARCHITECTjENGZNEER: _
<br /> �, Name• Frm Name:
<br /> Address: City: State: Zip:
<br /> i St�te License#: Phone: Cell: �a�c:
<br /> D cri 'on Pro' ct
<br /> TYPE O D,�tIV ,N,I�Y . „�I.EN6TH OP�DFtNEWAY � CtJLVER'ES�NEEDED
<br /> v/'����RESIDEM7AL pRNEWAY _,�'WID7}i OF DRNEWAY ( )REINFORCED CONCREfE.
<br /> COMMERQAL DRIVEWAY R.O.W, �JCCAVATION ( }CQRRUGATED MA`t'ERIAC.
<br /> PUBLTC ACCESS DRIVEWAY DEPTH LINEAR FEET ( )BOX CULVERT
<br /> ( )O'fHER(IXPLAIN)
<br /> COIHSFRUCTIOI+�MATERIA� CURB CUT REOUIR�D i
<br /> �PHAL7 YES NO
<br /> NCREfE I
<br /> HEADWALL REOUIRED? YES NO I
<br /> NOTICE TQ APPLICANT. If actual work exceeds scope of this description,additiona!permits ar drawings
<br /> will be required.
<br /> UTILITY LOCATICINS REQUIRED: CAl1.BEFORE YOU DIGc 1.8Q0.432.4770
<br /> Page 1 of 3
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