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F W HEgT~ City of Wheat Ridge Building Division
m 7500 W. 29th Ave., Wheat Ridge, CO 80033
Office: 303-235-2855 * Fax: 303-237-8929
~o~oRPao o Inspection Line: 303-234-5933
Pr .0eify Address;
Property Owner (please
Mailing Address: (if different than property address)
Address:
Date:
Plan
Permit
-21
l
City, State, Zip:
Contractor:
Contractor License ~A l Phone: Qba \ 6
Sub Contractors:
Electrical City License
Company:
Exp. Date:
Approval:
Use of space (description):
Description of,wor c
ILA 19
Sq. Ft./L.Ft added: Squares _
Plumbing City License
Company
Mechanical City License
Company:
Exp. Date: Exp. Date:
Approval: Approval:
Construction Value: $
(as calculated per the Building Valuation Data sheet)
Plan Review (due at time of submittal): $
BTU's Gallons Amps
OWNER/CONTRACTOR SIGNATURE OF UNDERSTANDING AND AGREEMENT -
I hereby certify that the setback distances proposed by this permit application are accurate, and do not violate applicable ordinances,
rules or regulations of the City _ of Wheat Ridge or covenants, easements or restrictions of record; that all measurements shown, and
allegations made are accurate; that I have read and agree to abide by all conditions printed on this application and that I assume full
responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other applicable Wheat Ridge Ordinances, for work
under this permit. Plans subject to field inspection.
CIRLCE ONE:: (OWNER) CONTRACT R or PERSONAL REPRESENTATIVE of (OW €R) (CONTRATOR) q
PRINT NAME. SIGNATURE~~7"F."i R4 \ Date: ~
if: MVf)
Bldg Valuation: $
Building Permit Application
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