HomeMy WebLinkAbout4271 SOUTHSHORE CT - APPLICATIONS - 7/30/2014O1-EWTHE-COUNTER PER T M ONLY
This application is to be used to apply for the following permits .only (check all that apply). O Air CondlHoning
0 Demolition (interior non-structural} a Electrical Alteration (not service change) ❑ Gas Lighter 0,Gas Lou
17 Heating Unit 0 Lawn Sprinkler ❑ Mobile Home replacement -gRoofing O Sewor Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line tO ►MoodrPellet Stove (must be EPA certified, provide make, model and
manufa urer).
Complete all applicable Information an the application. Incomplete applications will not be accepted.
Application Date D7 '?�0.2DI4•
Far of WWV only
lob Site Address (rwulmd)
Value of Construction gatior, materials, profit)
a 4-5cl>r4:hshclre Gl .
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Property Owner Name Address
Clty/State ZIP
Phone
M. a
Ax .
-15
Applicant Name Address
City/Statie Zip
phone Q -?14 -
A- c-4mUe �b MdQ P Cd $oS S
;LO-7-G60 0
Contractor Address
Ey/stela ZIP
Phone
Conb-ddnr aty of R. Collins Sates .Tax ?
Are you paying to ites here or by report? Liyere ❑ Report
sa�srrx��,,,6n,tr,rw„iredbyacrcwrr
Are you paying with your.trust account? Yes
❑ No
Is this a residential or commercial project? II$Residential ❑ Cammerdal
If residential, Is lG single. family Detached ❑ condo/townhome (Angle family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
if commercial, is it: 13 Bank O Bar ❑ Church D HobaWctel ❑ Medical office Cl Office ❑ Retail
C] Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes O No if yPs, you may creed to anted hUslrxrfc P.2sEwatlon
if titt5 is for a demolition perlmi v what year was thd-building constructed?-
Ifprmr & 1974 you NJ/// need an asba.stw assessment to su8mlt widh Gh/s applicator.
of
"if lawn sprinkler/badaiow prevcnrxr, must list licensed plumber. If RrsKme N0, must list licensed electrician.
Subcontractors: Ltsttrre msmpunyname aorl3lyaefRCvN/ns//cense
aje Mdan� plumber metAiir[IM . Roofer R- I SS9 Cther.
I hereby allmoWledge that I have read this application and state that the above lniermation is complete and correct- I agree to
comply with ail requirements contained herein and dry ordinances and state laws regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicantt �„ �• i''�._,._. Date
PrintName A vent} �in Y�yt I YlQ S Signatuttie i ; 'j'1� =