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<br />API>J.:i.C}\T][,O~ FOR I)P;R~nT
<br />GI'IY OF 7..EPUYl\:JII1..1..S
<br />nUH.DJUlllG nll:r.p!i.R'nm,NT
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<br />OWNER'S
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<br />NAME r.'~f 0 U~p; ~G,r", ~IO"r.
<br />ADDRF5S i:Jo 7j~(J7 2~T
<br />'- 'f ? ij / C) tb;;e; ,~c;J 1!'
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<br />7 ?~) -?/J?r
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<br />Oh"h'"ER ' S
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<br />."JOB ADDRESS
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<br />r//c- ~~frO'4
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<br />LE(",AL DESCRIPTION: LOT(S)
<br />I
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<br />-"
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<br />m.ocK
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<br />-smmI\"ISION1
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<br />PARCEL I. D. ~
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<br />h"ORK PROPOSED:_!S!e'A' Construction 1-^,ddil:ion -4Alteration _Repair _Install
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<br />_Sign
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<br />_HoV/e
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<br />_Demolish.
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<br />PROPOSED USE:
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<br />Single Falllily
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<br />_H/F
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<br />_~ of Unil:s
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<br />_~i/ II
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<br />4- l,ofiDIllercial
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<br />_Indus 1:.
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<br />_Swig. Peol
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<br />_____Other
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<br />_Resltaurant Ii: nealth Uepart1lilent: Approval
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<br />BUILDING SIZE:
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<br />x___,-----'--,
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<br />_____Square Fecl:,_. ~-
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<br />He;i.ght
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<br />RESIDENTIAL:. ATIACJI (2) PLOT PLA~S Ii (2) SETS OF mrrLDING Pti\INiS & (1) SET ENERGY FOR?'tS. H
<br />COMMERCIAL: ATTACI1 (3) SETS GF mJIJ.DIJNIG PIAN=> &(1) SET EINlf1:RGY FQR~tS. ~*
<br />~~COpy OF cowrnAGX RE'QIJ.J)'][P.,El)"
<br />
<br />_BUILDING
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<br />~ G.- {eJt1> ,;,.[_"","-..ITS RF.Q11F$TfJl
<br />Val,uaLion of Total (".onsLicuction
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<br />$
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<br />_ELECTRICAL
<br />-LHECIL-\};'"I CAT.
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<br />AMP Service
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<br />Plol:'ida PO\,Cl.- C:";~p.
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<br />\i.R.E.C.
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<br />$ ~c:::. t.eJ 0.-,1 c.-!- i'Valu.atim1c of iHechanicaL Tnstallation
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<br />_I-LU1'lBING
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<br />GA,$
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<br />_ .__..___ROOFI~G
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<br />____5PEC1.ALTY
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<br />TYPE OF CONSTRUCTION!: _Block
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<br />___Jra~ _ ___S t:eel.
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<br />.other
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<br />FIlIfISTlED FLOOR :ELEVATImUS- ~
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<br />,?--.:,~ ,
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<br />IS FRe.JECT IN FLOOD zom:: :'\RE."-?
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<br />YES NO
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<br />~~~~~~~~*~~~~t~~~~~~~~*~~~**~***t~~~~*~~~*
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<br />Signature
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<br />{<J
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<br />ooJWTP..Acror(, SF.CT'TON
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<br />n \TTT .0 Y.R
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<br />Icmu' f\.f!\W
<br />State (;.::rt. or: Regi,~;;l:. if!
<br />Cl. ~ - gn.se j"{cgist~~.rat:ion #
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<br />F.T.F.CTRIC1AN
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<br />U1ll'[P.Vi'Y
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<br />----.-------
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<br />St:.at{~ 'CeJ:'t:. or ]t.eg~~.:;;:r.: #:
<br />C:it.-y I.icense Regis,lC,C;\1i:ion jft
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<br />Signature
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<br />*~t~~i*~t~~~*~*~~~~~~~~*~~*~~~*~*~~~~'~:~~~~~
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<br />LlOO'irA~1Y
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<br />State Gert. or RegisL. ~
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<br />_.__ Cit:}". Ll'~'cdsle Regis !:.;c:;::'.".::.iCril ~~
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<br />PUliMRER
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<br />Signature
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<br />Sicnature,
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<br />OONP/!\ff,y.;;/jt-C./KS L: -{- A-l ItA/O
<br />State GerL or RcgisL iZ::if?;.'ol/ {".;Jc:JQ
<br />Git:,y I"icense Rel:>,ist:caLl.on :! -~ ~
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<br />HF.'ClTA ~"l CAT.
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<br />OTlrrn COHI'AR.i'
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<br />r:,~' >18lAA.~V"";:"-< Stat'~ CerL or RCl:>,isl:. ,.~--,
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<br />r t,_., . (..."':..~-'~...:~
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<br />APPLICATION APrRDVFD n-'~
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<br />PER.'fIT OFFICER.
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