HomeMy WebLinkAbout4465 Cody StreetCity of Wheat Ridge
Residential Roofing PERMIT - 201704663
PERMIT NO: 201704663 ISSUED: 07/24/2017
JOB -ADDRESS: 4465 Cody ST EXPIRES: 07/24/2018
JOB DESCRIPTION: Residential Re -roof to install GAF Timberline HD asphalt shingles with 28
sq.
*** CONTACTS ***
OWNER (303)424-8632 SCHMITT ROSEANN
SUB (720)708-4126 Terry Marks 130138 Home Guard Services LLC
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2406 / BEL AIRE,HILLCREST HEIGHTS, ME BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 7,196.00
FEES
Total Valuation 0.00
Use Tax 151.12
Permit Fee 172.60
** TOTAL ** 323.72
*** COMMENTS ***
*** CONDITIONS ***
Effective December 1, 2014, asphalt shingle installations require an approved midroof
inspection, conducted when 25-75 percent of the roof covering is installed, prior to final
approval. Installation of roof sheathing (new or overlay) requires an approved inspection
prior to installation of ANY roof coverings and is require on the entire roof when spaced
or board sheathing with ANY gap exceeding one half inch exists. Asphalt shingles are
required to be fastened to the roof deck with a minimum of 6 nails per shingle. Ice and
water shield is required. Eave and rake metal is required. A ladder extending 3 feet above
the roof eave and secured in place is required to be provided for all roof inspections.
Roof ventilation is required to comply with applicable codes and/or manufacturer
installation instructions, whichever is more stringent. In order to pass a final inspection
of elastomeric or similar type roof coverings, a letter of inspection and approval from the
manufacturer technical representative stating that "the application of the roof at (project
address) has been applied in accordance with the installation instruction for (roof
material brand name) roof covering" is required to be on site at the time of final
inspection.
Roof inspections for ROOFS OVER 6/12 PITCH: 3rd party inspection will be required, the 3rd
party inspection report will be collected at final roof inspection performed by City of
Wheat Ridge. If report is not available the final inspection will not be completed.
4 465 INSPECTION RECORD
INSPECTION ONLINE FORM: http://www.ci.wheatridge.co.us/inspection
INSPECTION REQUEST LINE: (303) 234-5933
Occupancy/Type
Inspections will not be performed unless this card is posted on the project site.
**Request an inspection before 11:59 p.m. (midnight) to receive an inspection the following business day.**
Inspector Must Sign ALL Spaces pertinent to this project
Foundation Inspections Date Inspector Comments
Initials
Pier
Concrete Encased Ground (CEG)
Foundation / P.E. Letter
IT7.R.7i-1TR'i.1111MMEMO TTiA±.�TiTZilrF.1noIMI@_Tmil6_riwxFfi-9.Z:TaOr.]IF-
Underground/Slab Inspections
Date
Inspector
Initials
Comments
Electrical
Sewer Service
a
Plumbing
nr% Hnt (_nuar I Inrlprnrniinrl nr Rpinw/In-Slah Work Prior To Anoroval UT I ne Anove Inspections
Rough Inspections
Date
Inspector
Initials
Comments
Wall Sheathing
Mid -Roof
a
Lath / Wall Tie
Rough Electric
Rough Plumbing/Gas Line
Rough Mechanical
Rough Framing
Rough Grading
Insulation
Drywall Screw / Nail
Final Inspections Date Inspector
Initials
Comments
Landscaping & Parking / Planning Dept.
Inspections from these entities should be requested
one week in advance. For landscaping and parking
inspections call 303-235-2846. For ROW and drainage
inspections call 303-235-2861. For fire inspections
contact the Fire Protection District for your project.
ROW & Drainage / Public Works Dept.
Floodplain Inspection (if applicable)
Fire Inspection / Fire Protection Dist.
Final Electrical
Final Plumbing
Final Mechanical
Roof 1 o.. 19- UZ
Final Window/Doors
Final Building
NOTE: All items must be completed and approved by Planning, Public Works, Fire and Building before a Certificate
of Occupancy is issued. Approval of the Final Building inspection does not constitute authorization of occupancy.
`For low voltage permits - Please be sure that rougn inspections are compietea rrom the Tire uistnct ana eiectncai ww vurtaye
by the Building Division.
Occupancy Is Not Permitted Until A Certificate of Occupancy Is Issued
Protect This Card From The Weather
L/
i CITY OF WHEAT RIDGE
_��9�Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: Ll 0 9 -
Job Address: Ll L/ 4, r rc c 4 -
Permit Number: 2 V / -7 d Ll (o � 3
rte- n o� I � P P
❑ No one available for inspection: Time :�/ ' 3q gR/PM
Re -Inspection required: Yes Mo
When corrections have been made, call for re -inspection at 303-234-5933
Date: ) 2/1-7 Inspector: 'T`_�>
DO NOT REMOVE THIS NOTICE
� City of Wheat Ridge
Residential Roofing PERMIT - 201704663
PERMIT NO: 201704663 ISSUED: 07/24/2017
JOB ADDRESS: 4465 Cody ST EXPIRES: 07/24/2018
JOB DESCRIPTION: Residential Re -roof to install GAF Timberline HD asphalt shingles with 28
sq.
*** CONTACTS ***
OWNER (303)424-8632 SCHMITT ROSEANN
SUB (720)708-4126 Terry Marks 130138 Home Guard Services LLC
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2406 / BEL AIRE,HILLCREST HEIGHTS, ME BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 7,196.00
FEES
Total Valuation 0.00
Use Tax 151.12
Permit Fee 172.60 z.+ a s ,
** TOTAL ** 323.72
*** COMMENTS ***
*** CONDITIONS ***
Effective December 1, 2014, asphalt shingle installations require an approved midroof
inspection, conducted when 25-75 percent of the roof covering is installed, prior to final
approval. Installation of roof sheathing (new or overlay) requires an approved inspection
prior to installation of ANY roof coverings and is require on the entire roof when spaced
or board sheathing with ANY gap exceeding one half inch exists. Asphalt shingles are
required to be fastened to the roof deck with a minimum of 6 nails per shingle. Ice and
water shield is required. Eave and rake metal is required. A ladder extending 3 feet above
the roof eave and secured in place is required to be provided for all roof inspections.
Roof ventilation is required to comply with applicable codes and/or manufacturer
installation instructions, whichever is more stringent. In order to pass a final inspection
of elastomeric or similar type roof coverings, a letter of inspection and approval from the
manufacturer technical representative stating that "the application of the roof at (project
address) has been applied in accordance with the installation instruction for (roof
material brand name) roof covering" is required to be on site at the time of final
inspection.
Roof inspections for ROOFS OVER 6/12 PITCH: 3rd party inspection will be required, the 3rd
party inspection report will be collected at final roof inspection performed by City of
Wheat Ridge. If report is not available the final inspection will not be completed.
A f City of Wheat Ridge
r Residential Roofing PERMIT - 201704663
PERMIT NO: 201704663 ISSUED: 07/24/2017
JOB ADDRESS: 4465 Cody ST EXPIRES: 07/24/2018
JOB DESCRIPTION: Residential Re -roof to install GAF Timberline HD asphalt shingles with 28
sq.
I, by my signature, do hereby attest that the work to be performed shall comply with all accompanying approved plans and specifications,
applicable building codes, and all applicable municipal codes, policies and procedures, and that I am the legal owner or have been authorized
by the legal owner of the property and am authorized to obtain this permit and perform the work described and approved in conjunction with
this ermrt. I further attest m le ally authorized to include all entities named within this document as parties to the work to be
ormed and that all wor to be orm d is disclosed in this document and/or its' accompanying approved plans and specifications.
Signature of OWNER or CONTRACTOR (Circle one) Date
1. This permit was issued based on the information provided in the permit application and accompanying plans and specifications and is
subject to the compliance with those documents, and all applicable statutes, ordinances, regulations, policies and procedures.
2. This. permit shall expire 365 days after the date of issuance regardless of activity. Requests for extension must be made in writing and
received prior to the date of expiration. An extension of no more than 180 days made be granted at the discretion of the Chief Building
Official and may be subject to a fee equal to one-half of the original permit fee.
3. If this permit expires, a new permit may be required to be obtained. Issuance of a new permit shall be subject to the standard
requirements, fees androcedures for approval of any new permit. Re -issuance or extension of expired permits is at the sole discretion of
the Chief Building Official and is not guaranteed.
4. No work of any manner shall be performed that shall results in a change. of the natural flow of water without prior and specific approval.
5. The permit holder shall notify the Building and Inspection Services Division in accordance with established policy of all required
inspections and shall not proceed or conceal work without written approval of such work from the Building and Inspection Services
Division.
6. The issu a or granting of a permit shall not be construed to be a permit for, or an approval of, an violation of any provision of any
applic a co a or any ordins ani or regal ion of this jurisdiction. Approval of work is subject to field inspection.
Signature of Chief Building Official Date
REQUESTS MUST BE MADE BY 11:59PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
Dan Schultz
1704-�e'e'13
From: no-reply@ci.wheatridge.co.us
Sent: Friday, July 14, 2017 2:25 PM
To: Permits CommDev
Subject: Online Form Submittal: Residential Roofing Permit Application
Categories: Danny
Residential Roofing Permit Application
This application is exclusively for new permits for residential roofs and for licensed
contractors only. This type of permit is ONLY being processed online --do not come
to City Hall to submit an application in person. Permits are processed and issued in
the order they are received and due to the volume of requests, time to process
varies and is subject to change. YOU WILL BE CONTACTED WHEN YOUR
PERMIT IS READY FOR PICK-UP AND WILL BE GIVEN A SPECIFIC DATE
AND TIME WINDOW TO COMPLETE THE TRANSACTION. You will be notified if
your contractor's license or insurance has expired, and you may update those
documents at the time you are issued your permit.
For all other requests:
Homeowners wishing to obtain a roofing permit must apply for the permit in person
at City Hall. Revisions to existing permits (for example, to add redecking) must be
completed in person at City Hall. All other non -roofing permits must be completed in
person at City Hall. The Building Division will be open from 7:30-10:30 a.m.,
Monday through Friday to process these types of requests.
THIS APPLICATION DOES NOT CONSTITUTE A PERMIT. DO NOT BEGIN
REROOFING UNTIL PERMIT HAS BEEN ISSUED.
Is this application for a Yes
residential roof?
How many dwelling units Single Family Home
are on the property?
PROPERTY INFORMATION
Property Address
Property Owner Name
Property Owner Phone
Number
Property Owner Email
Address
4465 Cody St
Roseanne Schmitt
303-424-8632
Field not completed.
1� --s 2_-�; - ? ;�-
Do you have a signed
Yes
contract to reroof this
property?
It will need to be
provided at the time of
permit pick-up.
CONTRACTOR INFORMATION
Contractor Name
HomeGuard Restoration
Contractor's License
130138
Number (for the City of
Wheat Ridge)
Contractor Phone
7207084126
Number
Contractor Email Address
fernl@homeguardroof.com
Retype Contractor Email
fernl@homeguardroof.com
Address
DESCRIPTION OF WORK
/
Are you re -decking the
No
roof?
Description of Roofing
GAF Timberline HD
Material
Select Type of Material:
Asphalt
If "Other" is selected
Field not completed.
above, describe here:
How many squares of the
26
material selected above?
/
Does any portion of the
No
property include a flat
roof?
If yes, how many squares
Field not completed.
on the flat roof?
j
TOTAL SQUARES of all
28
roofing material for this
proj ect
Provide additional detail
Replace house roof. Pitch 4/12
here on the description of
2
work. (Is this for a house
or garage? What is the
roof pitch? Etc)
Project Value (contract 1ta& L
value or cost of ALL
materials and labor)
SIGNATURE OF UNDERSTANDING AND AGREEMENT
I assume full Yes
responsibility for
compliance with
applicable City of Wheat
Ridge codes and
ordinances for work
under any permit
issued based on this
application.
I understand that this Yes
application is NOT a
permit. I understand I will
be contacted by the City
to pay for and pick up the
permit for this property.
I understand that work Yes
may not begin on this
property until a permit
has been issued and
posted on the property.
I certify that I have been Yes
authorized by the legal
owner of the property to
submit this application
and to perform the work
described above.
Name of Applicant Fern Lytwyn
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o s CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234 -5933 Inspection line
{303) 235 -2855 Office • (303) 237 -8929 Fax
INSPECTION NOTICE
Inspection Type:��
Job Address:
Permit Number: OX 3
❑ No one available for inspection: Time AM /PM
Re- Inspection required: Yes No
When corrections have been made, calf for re inspection at 303 - 234 - 5933
Date: Inspector:
DO NOT REMOVE THIS NOTICE
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
r' (303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: } ~J
Job Address: I} Vl
Permit Number: 5 } f /
❑ No one available for inspection: Time AM/PM
Re-Inspection required: Yes No
*When corrections have been made, call for re-inspection at 303-234-5933
Date: ! c, inspector: }
DO NOT REMOVE THIS NOTICE
-°4i. ~ .5 YO V'•` E 3R~ i~.a vv-T[^. ~K i`i "S,"yG
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
r
Inspection Type:
Job Address: 41 g h S ^ A-j 7-
Permit t Number: y ` f
I
t
i
i
❑ No one available for inspection: Time AM/PM
Re-Inspection required: Yes No
When corrections have been made, call for re-inspection at 303-234-5933
Date: 0!z Inspector:
DO NOT REMOVE THIS NOTICE
" ' City of Wheat Ridge
Faxed Roof Permit PERMIT - 093477
r4000or PERMIT NO: 093477 :ISSUED:' 10/19/2009
JOB ADDRESS: 4465 CODY ST 'EXPIRES: 04/17/2010
DESCRIPTION:P Reroof 527 sqs and redeck.
CONTACTS
c' owner 303/424-8632 Rose Ann Schmitt
sub 303/763-9114 Lorin Hanson 01 -9938 Interstate Roofing Incorporate
PARCEL INFO
ZONE iCODE: UA ! -USE: UA
SUBDIVISION:! 0236.`BLOCK/LOT#: 0./
FEE SUMMARY ESTIMATED PROJECT VALUATION: 7,290.00,
r FEES
Permit Fee 199.30
Permit fee additiona 146.27
Total Valuation .00 f'..
Use Tax 131.22 "
**.TOTAL -476.79
Conditions:
~I
Both !front and back of permit need to be posted on job site. If one or the other
is not present, INSPECTION WILL NOT BE PERFORMED.
6 nail installation & mid roof inspection required. Board sheathing spaced more
than a 1/2 of an inch apart requires plywood overlay on entire roof. Ice and
water :shield '-required from eave edge to 21 inside exterior walls.
***Contractor/Property owner shall provide ladder(s) secured in place for..
inpsections.
Subject to field inspection.
. 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
};v 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.
i~
signature of contractor/owner :date
1. This permit was issued in accordance with the <provisions set forth in your application and is subject to the laws of the
state of Colorado and to the Zoning. Regulations and Building Codes of Wheat Ridge, Colorado or any other applicable
ordinances of the City.
r ---r---..--- ~-r .moo c uu cc....cyuw co. w. . m~c.mi a ~wav ua aawivau-Pc..uc w-exy its uou
date. An extension may:. be granted at the discretion of the Building Official:.
If this permit expires, a new permit may be acquired for a fee of one-half the amount normally required, provided no
changes have been or will be made in the original plans and specifications and any suspension or abandonment has not
exceeded one '(1) year. If changes have been or if suspension or abandonment exceeds one (1) year,--<full fees :shall _
be paid for a; new permit.
No work of any. manner shall be done that will change the natural flow of water causing adrainage problem.
Contractor shall notify the Building Inspector twenty-four (24) hours in advance for all inspections and shall receive
written approval on inspection card before proceeding with successive phases of the job.
The issuance o pa permit or the approval of drawings and specifications shall not be construed to be a permit for, nor
an app v o any violation of the provisions of the building codes or any other ordinance, law, rule or regulation.
All p w is subject to field inspections.
ignatuv of Chief: Building Official date
NSPECTION REQUEST LINE: (303)234-5933 BUILDING OFFICE:. (303)235 2855.':
EQUESTS MUST •BE.MADE BY 3PM.: ANY BUSINESS DAY FOR:'INSPECTION THE ' FOLLOWING :BUSINESS DAY.
Interstate Roofing
11452 W. Hampden PI.
Denver, CO 80227
October 27, 2009
To whom it may concern;
This is to state that Wheat Ridge has the right to use the credit card on file to charge for re-deck permit.
This is to be added to permit number 093477, with address 4465 Cody St.
Thank you
~WC
" 41
V, City of Wheat Ridge
J
Faxed Roof Permit PERMIT - 093477
PERMIT NO: 093477 'ISSUED: 10/19/2009
JOB ADDRESS: 4465 CODY ST EXPIRES: 04/17/20.10
DESCRIPTION: Reroof-27 sqs..
CONTACTS
owner 303/424-8632 Rose Ann Schmitt
sub 303/763-9114 Lorin Hanson 01-9938 Interstate Roofing Incorporate
**PARCEL <INFO
ZONE :CODE: UA USE: UA
SUBDIVISION:' 0236 BLOCK/LOT#: 0/.
FEE SUMMARY ESTIMATED PROJECT VALUATION: 7,290.00:
FEES
Permit Fee 199.30
Total Valuation ` .00 rl u`~ Use 'Tax 131.22
TOTAL 330.52
Conditions:,
Both front and back of permit need to be posted on job site. If one or the other
is not present, INSPECTION WILL NOT BE PERFORMED.
6 nail installation & mid roof inspection required. Board -sheathing spaced more
thana 1/2 of an inch apart requires plywood overlay on entire roof. Ice and
water shield` required from eave edge to 2' inside exterior walls.`
***Contractor/Property owner shall provide ladder(s) secured in place for
inpsections.°
Subject to field inspection.
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 otherv
applicable Wheat Ridge Ordinances, for work under this permit. Plans subject to field inspection.
Signature of contractor/owner date
1. This permit was issued in accordance with the provisions set forth in your application and is subject to the laws of the.
state of Colorado and to the zoning. Regulations and Building Codes of Wheat. Ridge, Colorado or any other applicable
ordinances of the city.
2. This permit shall expire 180 days from the issue date. Requests for. an extension must be received prior to expiration
date. An extension may. be granted at the discretion of'. the Building Official;
3. If this permit: expires, a new permit may be acquired fora fee of one-half the amount normally required, provided no
changes have been or will. be made in the original plans and specifications and any suspension or abandonment has not
exceeded one (1) year. If changes have been or if suspension or abandonment exceeds one (1) year, full fees shall
be !paid for anew permit.
k. No work of any.: manner shall be done that will change the natural flow of water. causing adrainage problem.
o. Contractor shall notify the Building inspector twenty-four (24) hours in advance for all`. inspections and shall receive
written approval on inspection card °before proceeding with successive phases of the jobs.
The issuance of a permit or the approval of drawings and specifications shall not be construed to be a permit for, nor
an approval of, any violation of the provisions of the building codes or any other ordinance, law, rule or regulation.
AlI:plan r ie subject to field Inspections.
lignatur of e f'FBuilding ;Offi cia
CN l date
SP TION R8Q U8ST LINE: (303.)234-5933 BUILD ING ; OFFICE: (303)235-2855
ZEQUESTS UST BE MADE BY 3PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING. BUSINESS DAY.
INSPECTION RECORD Occupancv/TVpe
'V INSPECTION LINE: (303) 234-5933
Inspections will not be made unless this card is posted on the building site
Call by 3:00 PM to receive inspection the following business day.
INSPECTOR MUST SIGN ALL SPACES PERTAINING TO THIS JOB
FN TION INSPECTIONS DATE
INSPECTOR
INITIALS
COMMENTS:
Caissons
$
/ (CEG) Concrete
Ground
g or Monolithic
roof/ French Drain
rvice Lines
Water Service Li nes
CONCRETE SLAB FLOOR
Electrical
Plumbing
ROUGHS
Sheathing
Lath /Wall tie
Mid-Roof
Electrical Service
Rough Electric
CONCRETE UNTIL ABOVE HAS
UNTIL
Rough Plumbing
Gas Piping
Rough Mechanical
ABOVE INSPECTIONS TO BE SIGNED PRIOR TOP CITY OF WHEAT RIDGE
Framing 19/19/09 2133 PM edbb
Insulation Robert Fowler
Drywall Screw Wr N'T Bn.rRDrr,nan
FINALS
Electrical
sqs
30
sqs
Mechanical
= w.u ree
Use TR
162.90
90
72
Roof
erooi 27 =
qs
.
264.96
093489
Building Final
-
Permit Fee
Use Tax
162.90
Fire Department
102.06
R.O.W & Drainage
INSPECTIONS F
PAYMENT RECEIVED
PA 495®
AMOUNT
849
10
Parking & Landscaping
SHOULD BE CA
Auth Code:
93532E
.
**NOTE: ALL ITEMS MUST BE COMPLETED AND APPROVED BY PLANNING AND
!TOTAL
$49.10
CERTIFICATE OF OCCUPANCY IS ISSUED. FINAL INSPECTION BY THE BUILDIN
OF A CERTIFICATE OF OCCUPANCY NOR PERMISSION FOR OCCUPANCY.
OCCUPANCY NOT PERMITTED UNTIL CERTIFICATE OF OCCUPANCY IS ISSUED
PROTFCT THIS CARn FROM THE WFATHFR
♦1, r
v I City QI Date;
jr 'Wheat id e y
COMMUNi7Y DEVELOPMEt4T Permit t
Building Division
7500 W. 29et Ave., Wheat Ridge, CO 800.$3
Office: 303-235-2855 * Fax: 303-237-89,2J
Inspection Line: 303-234-5933
aabq I
Property Address:
Property Owner (plea
Use of space description):
. q ~/Mqnt/'vt►~(~11CiQ aP ~dlC~ U
~I etK "vY=
Sq. FUL.Ft added: J Squares 0 BTU's
Consin,iction Va'tho:.5
Plan Ravlewr (due Ot tfine ofsubmftfal): S
OWNERICONTRACTOR SIGNATURE OF UNDERSTANDING AND AGREEMENT
I hereby certify that the setback distances proposed by this permit application are accurate, and' do not violate applicable ordinances,
rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of ra&oMd; that all measurements shown, and
allegations made are accurate; that I have read and agree to abide by All conditions printed ou hils application and that I assume full
raspansibliity for compliance with the Wheat Rldgge Building Code (I.B.C) and all other appiicable Wheat Ridge Ordinances, for work
under this permit. Plana subject to field Inspection.
CtRLCE ONE;; (OWNER) (CONTRACTOR) or PERSONAL REPRESENTATIVE of (OWNER) (CONTRATOR)
PRINT NAME; SIGNATURE;
ZONgOi3tp;t9:
~atinnirr$;
Y:
Pt16'!ulr9~ tom;
Flrt@fl t 47 e1n+ ar i ;dfsdpPnavad ❑ no:te7r4wW401w,
valuation:
Date;
Credit Card y t' Us aftja~ listed on
Print name: T r Signatul
Facsimile Building Permit Application
Malting Address: (if different than property address)
Address