HomeMy WebLinkAbout4619 Crest Rd - Applications/Reroof - 08/05/20140VFwR-T"Fw- UN-tl hK l KIVID Its UNLY
This application to to be used to apply for the following permits only (check all that apply). 0 Alr Conditioning
Q Demolition (Interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter 0 Gas Log
• Heating Unit 0 Lawn Sprinkler n Mobile Home replacement �[ Roofing 0 Sewer Line 17 Photo-voltetc
Q Ventilation 0 Wafer Heater n Water Line i7 WcodlPollet Stove (mustbe EPA certified, provide make, model and
manufacturer)_
COmDtete all applicable information on
the application. Incomplete appliications will not be acceptad.
Application q
Foradri'a? use onlr
Job site Address ereqdd)
Value of Construction (labor, materials, proiit3
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Property Owner NOrne Address
City/State Zip Phone
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Applicant Name Address
Litylstate ZIP Phone 4 w -
AJG ,,UAe 'P�oF1 Svrc 10 W T��6 C FTC ca aaaS a't.07-0000
Contractor Address
ity/staIB Zip Phone
Contactor City of It colfins Sates Tax
Are you paying taxes here or by report? D Report
Files 0 NO
mar tax MM&Or&rwaftadbyeucrr,rfrwkvlr
Are you paying with your trust account?
is this Pi residential or eommerdai project? Residential 13 Commercial
If residential, is it: iai single Family Detached 17 Conde/townhome (s nple Family attached) 0 Duplex
0 Muit> rr fy (apartment) ❑ Garage
It commercial, Is ft. ❑ Bank 0 Bar ❑ Church ❑ Hobal/Motet ❑ Medical office ❑ Office ❑ Retail .
❑ Restaurant ❑ Other (explain)
Is titis building So years or age or more? ❑ Yes ❑ No Ifyea, yourmsyfre�td m cnntactHu07nic PPasP�trahbem
If this is for a demolition pet7nit;, what year was thd-buitding consblidW ?
lirQrlor Lo i97$ ycu wffl need an asbegas assatasmemt iG submitW& this BA01m bA
of work
`�If lawn spdnider/baddlow prevcntrr, must i►st Moaned plumber. If firsbame Aft, must qsC Itaensed eln.
Subcontractors: List d1ccvmFanrnamaOrOryaFRCbl Nffeense't
flecat anrraber Metrinnr 't Roo�� R- 1859 other
1 hereby adumMedge that I have read this application and doate that the above information is complete and coerce:. I agree to
comply wttit all requirements cant Aned herein and city ordinances and state laws regulating bufidtm} construction. I know that a
permit to notvalid until it has been paid and issued.
i
Applicant: �1 �—
Print Namo:.,,N'"tiy �� � S Sf_gnaUir