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CITY ZI TELEPHONE NUMBER
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NAME
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CITY
ZIP ITELEPHONE NUMBER
USE PERMIT U 0 /� .
ZONE NUMBER LFV
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ADDRESS 3d5
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r FGAL DESCRIPTION CHECKI SUBDIVISION NO. LID NO.
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP. APPROVED BY
EXISTING REQUIRED DEDICATION
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RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED 0
STREET USE PERMIT REQUIRED ❑
REVIEW BY
SEE ENGINEERING MEMO DATED
REMARKS
NAME
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^ ZIPTP�OEMCBECR OD REMARKS
STA LICE E NUMB R
BUILDI
SIGN AREA
ALLOWED I PROPOSED
Legal Description of Property - include all easements
(show below or attach two copies)
Tax Account Parcel No.
0 NEW NII,,RESIDENTIAL
ElADDIALTER F COMMERCIAL
REPAIR APT. BLDG.
ElEXCAVATE, FILL
L� DEMOLISH OR GRADE
CARPORT
REMODEL GARAGE
❑ WOOD STOVE ❑ RETAINING WALL/
INSERT ROCKERY
(TYPED USE, BUSINESS OR ACTIVITY) EXPLAI
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NUMBER OF STORIES NUMBERDWELLINF
UNITS
NA RE OF WORK ffl BE DONE ATTACH PLOT
N VARIANCE OR CU
PLUMBING
I SIGN
FENCE
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I-1 SWIM
ElRENEWAL
SETBACKS — FEET
FRONT SIDE
PPLY SIZE IFIXTURE UNITS
ENV. REVIEW ADB NO.
COMPLETE I EXEMPT
SHORELINE q
REVIEW BY I DATE
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HEIGHT LOT COVERAGE ?
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BY TYPE OF CONSTRUCTION
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!R AREA OCCUPANCY OCCUPANT
GROUP LOAD
NO
INSPECTIONS PER UBC 305
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FINAL INSPECTION REQUIRED
VALUATION
PLAN CHECK FEE
Plan Check No.
MINOR• • •. •
STATE SURCHARGE
Permit Application: 180 Days
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ProvidedPermit Limit: 1 Year - .•�
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PLAN CHECK DEPOSIT
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FEE
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APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his
Deputy; and fees are paid, and receipt is
acknowledged in space provided.
OFFICI SIGNQTURF, PATE I
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ED BY:
ORIGINAL — File YELLOW — Inspector
PINK — Owner GOLD — Assessor ./
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