HomeMy WebLinkAbout4301 Jellison StreetINSPECTION RECORD
INSPECTION ONLINE FORM: http://www.ci.wheatridge.co.us/inspection
INSPECTION REQUEST LINE: (303) 234-5933
Cancellations must be submitted via the online form before 8 a.m.,the day of the inspection
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 pe. ' e o this ,roje
Foundation Inspections Date Inspecto ' om ts.
Initials
Pier r
Concrete Encased Ground (CEG) _
Foundation / P.E. Letter
Do Not Pour Concrete Prior To Approval Of The AVbve InspeiCtions
Underground/Slab Inspections Date Inspector Comments
Initials
Electrical
Sewer Service
Plumbing
Do Not Cover Underground or Below/In-Slab Work Prior To Approval Of The Above Inspections
Rough Inspections
Date
Inspector
Initials
Comments
Wall Sheathing
Mid -Roof `
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
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 rough inspections are completed from the Fire District and electrical low voltage
by the Building Division.
Occupancy Is Not Permitted Until A Certificate of Occupancy Is Issued
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City of Wheat Ridge
Residential Roofing PERMIT - 201706074
PERMIT NO: 201706074 ISSUED: 08/14/2017
JOB ADDRESS: 4240 Iris CT EXPIRES: 08/14/2018
JOB DESCRIPTION: Residential Re -roof to install asphalt shingles - 27.53 sq
*** CONTACTS ***
OWNER (720)974-7815 FICCO VICTORIA
SUB (303)777-7999 Rick Carter 018009 Palace Construction Co., Inc..
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2002 / KIPLING, I-70 & CLEARCREEK ARE BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 11,659.00
FEES
Total Valuation 0.00
Use Tax 244.84
Permit Fee 236.00
** TOTAL ** 480.84
*** 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) is required on the entire roof
when spaced or board sheathing with ANY gap exceeding one half inch exists. Sheathing and
mid -roofs may be called in at the same time, one hundred percent of the sheathing must be
complete and 25-75 percent of the mid -roof may be complete. 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.
City of Wheat Ridge
Residential Roofing PERMIT - 201705671
PERMIT NO: 201705671 ISSUED: 08/08/2017
JOB ADDRESS: 4301 Jellison ST EXPIRES: 08/08/2018
JOB DESCRIPTION: Residential Re -roof to install IKO Cambridge asphalt shingles - 33 sq (20
sq pitched / 13 sq flat)
*** CONTACTS ***
OWNER (720)232-5600 VIEIRA RICHARD J
SUB (720)333-3819 Gerald Schafer 090409 Schafer Roofing Inc
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2002 / KIPLING, I-70 & CLEARCREEK ARE BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 15,519.93
FEES
Total Valuation 0.00
Use Tax 325.92
Permit Fee 299.40
** TOTAL ** 625.32 "-
*** 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) is required on the entire roof
when spaced or board sheathing with ANY gap exceeding one half inch exists. Sheathing and
mid -roofs may be called in at the same time, one hundred percent of the sheathing must be
complete and 25-75 percent of the mid -roof may be complete. 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.
o a i i City of Wheat Ridge
Residential Roofing PERMIT - 201705671
PERMIT NO: 201705671 ISSUED: 08/08/2017
JOB ADDRESS: 4301 Jellison ST EXPIRES: 08/08/2018
JOB DESCRIPTION: Residential Re -roof to install IKO Cambridge asphalt shingles - 33 sq (20
sq pitched / 13 sq flat)
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 permit. I further attest that I le ally aut ized to include all entities named within this document as parties to the work to be
performed and twat all wo to e p ed ' isc sed in this document and/or its' accompanying approved plans and specifications.
Signature of OWNER: or CO CTOR (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 maybe subject to a fee equal to one-half of the originalpermit 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 changeof 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 issuance or granting of a permit shall not be construed to be a permit for, or an a roval an violation of any provision of any
applicabl or any ordinance or regulation of this jurisdiction. Approval w s su ' ct to f eld inspectii
�1.11�t�
Signature of Chief Building Official Date
REQUESTS MUST BE MADE BY 11:59PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
Dan Schultz
`Z-�I OSh�I
From: no-reply@ci.wheatridge.co.us
Sent: Tuesday, August 1, 2017 8:58 AM
To: CommDev Permits
Subject: Online Form Submittal: Residential Roofing Permit Application
Categories: Gina
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?
;1 NOIN XZ4 VA 104 1201CLTA MAN •\
Property Address
Property Owner Name
Property Owner Phone
Number
Property Owner Email
Address
4301 Jellison St -�>(_
Richard Veiera
720-232-5600
rjv605@comcast.net
Do you have a signed
Yes
contract to reroof this
property?
20
It will need to be
provided at the time of
Yes
permit pick-up.
Attached Copy of
4301 Jellison cntrct0001.pdf
Contract
13
CONTRACTOR INFORMATION
Contractor Business
Schafer Roofing Inc.
Name
(pitched + flat) of all
Contractor's License
090409
Number (for the City of
Wheat Ridge)
Contractor Phone
720-333-3819
Number
Contractor Email Address
jerry@schaferroofing.com
Retype Contractor Email
jerry@schaferroofing.com
Address
DESCRIPTION OF WORK
Are you re -decking the
No j
/
roof?
Description of Roofing IKO Cambridge IR shingles and S/A Modified
Material
Select Type of Material: Asphalt, Rolled
If "Other" is selected
Field not completed.
above, describe here:
How many squares of the
20
material selected above?
Does any portion of the
Yes
property include a flat
roof?
If yes, how many squares
13
on the flat roof?
TOTAL SQUARES
33
(pitched + flat) of all
K
roofing material for this
proj ect
Provide additional detail
here on the description of
work. (Is this for a house
or garage? What is the
House has 8/12 and 1/12, Garage is 6/12
roof pitch. Etc)
Project Value (contract C 15519.93
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 Gerald Schafer
Email not displaying correctly? View it in your browser.
3
SCH�► /�OOFNG JNC,
COMM wne- rated
Remittance: PO Box 740939 Arvada, CO 80006-0939
Ph. 720-333-3819 * Fax 720-362-5060
May 25, 2017
Richard Vieira
4301 Jellison St.
Wheat Ridge, CO 80033
Job Address: 4301 Jellison St.
Schafer Roofing Inc., hereinafter called the "Contractor" proposes to ftimish labor and material necessary
to complete the following work according to the following specification:
Re: Reroof
Prepare roof deck as needed for proper installation of new materials including, complete
removal of existing roofing.
Install ice and water shield at shingles eaves to meet code.
Install new synthetic underlayment over the remaining roof deck.
Install new prepainted metal drip edge and rake edge flashings.
Replace all plumbing pipe jack flashings.
Replace all flue pipe cap flashings.
Install IKO Cambridge IR Lifetime fiberglass dimensional type shingles as per
manufacturer's specifications.
Install granular surfaced modified bitumen roofing system on the south low slope roof.
Remove all work related debris from job site.
All work to be done in accordance with local building codes.
A 2yr workmanship and manufacturer's warranty will be issued upon completion.
COST OF THE ABOVE WILL BE $11,229.90 House
$2,790.03 Garage
Install new 5' prepainted steel gutters and 299x 3" downspouts.
$1,500.00 House and garage
This proposal includes all necessary taxes, licenses and may be withdrawn by Schafer Roofing, Inc., if not
accepted within (30) days. Contract commencement will be determined at the execution of this contract.
Approximate Start Date: Approximate Completion Date:
Accepted By:�, t_L ( Respectfully Submitted,
Schafer Roofing Inc.
Title:
Date: 2— Z -_ t Je 7to.ection
r, r ident
Owner has 72 hours right of rescission of this contract from the date of acceptan a pu uant 6-22-104. Notification to be sent within 72
hours to Contractor by mail, electronic transmission or personal delivery. Owner ay also rescind this contract for service within 72 hours after
receiving notice from insurer that the claim has been denied in whole or in part. Upon rescission, any payments or deposits made by Owner to
Contractor shall be returned within ten days. Any payment made to by Property Owner to Contractor for materials shall be held in trust until
Contractor has delivered material to job or performed the majority of the work on the residential property. Pursuant to part 1 of article 4 of title 10,
C.R.S., Contractor cannot pay, waive, rebate all or part of any insurance deductible applicable to the insurance claim for payment of the roofing work
on the covered residential property. General Liability Insurance coverage provided by Hanover Limited, Worker's Compensation by Pinnacol
Assurance Frontier Insurance Agency 303456-9900
TERMS AND CONDITIONS
Schafer Roofing, Inc. (Hereinafter referred to as "Contractor")
1. CONDITIONS: All material is guaranteed to be as specified. All work is to be completed in a workmanlike manner according to
standard practices. Any alteration or deviation from specifications involving extra costs will be executed only upon written orders, and will become
an extra charge over and above the estimate. Owner to carry property and casualty insurance, including coverage for fire, wind damage, hail, tomado,
vandalism, and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance.
2. PAYMENTS ARE TO BE MADE: $0.00 UPON SIGNATURE OF CONTRACT AND BALANCE ON DAY OF SUBSTANTIAL
COMPLETION OF WORK. OTHER ARRANGEMENTS MUST BE DISCUSSED WITH CREDIT MANAGER. ALL PAYMENTS SHOULD BE
MADE PAYABLE TO "SCHAFER ROOFING, INC." ONLY.
3. SHOULD DEFAULT BE MADE IN PAYMENT OF THIS CONTRACT, CHARGES SHALL BE ADDED FROM THE DATE THEREOF
AT A RATE OF ONE AND ONE HALF PERCENT PER MONTH, (18% PER ANNUM) WITH A MINIMUM CHARGE OF $2.00 PER MONTH.
AND IF PLACED IN THE HAND OF AN ATTORNEY, ALL SUCH COSTS WILL BE ADDED TO TOTAL OWED.
4. Schafer Roofing, Inc. assumes no responsibility for structural integrity of the roof deck or the building on which the roofing is to be
installed. Customer represents all structures to be in sound condition capable of withstanding normal roofing construction and operations.
5. Owner must provide access for the loading and downloading of materials and contractor assumes no responsibility for cracks or scraps to
concrete or asphalt driveways, sidewalks, pathways or parking lots.
6. This proposal and contract is based upon the work to be performed by Contractor not involving asbestos — containing or toxic materials and
that such materials will not be encountered or disturbed during the course of performing the work. In the event that such materials are encountered,
Contractor shall be entitled to reasonable compensation for all additional expenses incurred as a result of the presence of asbestos -containing or toxic
material.
7. Contractor shall not be responsible for loss, damage, or delay caused by circumstances beyond its reasonable control, including but not
limited to acts of God, weather, accidents, fire, vandalism, regulation, strikes, labor controversies, failure or delay of transportation, shortage of or
inability to obtain material. Contractor is not required to remove snow, ice or water from roof.
Contractor not responsible for the removal or replacement of solar panels or satellite dishes.
9. Customer acknowledges that re -roofing may cause vibration, disturbance, dust or debris to fall into the interior. Customer agrees to
damage, clean-up or loss to interior property that Customer did not remove or protect prior to commencement
remove or protect property directly below the roof in order to minimize potential interior damage. Contractor shall not be responsible for disturbance,
of roofing operations. Customer shall
notify tenants of re -roofing and the need to provide protection underneath areas being re -roofed. Customer agrees to hold Contractor harmless from
claims of tenants who were not so notified and did not provide protection.
10. Contractor and Owner are committed to acting promptly so that roof leaks are not a source of potential interior mold growth. Customer
will make periodic inspections for signs of water intrusion and act promptly; including notice to Contractor if Customer believes there are roof leaks.
to correct the condition. Upon receiving notice, Contractor will make repairs promptly so that water entry through the roofing installed by Contractor
is not the source of moisture. Contractor is not responsible for indoor air quality. Customer is to maintain the interior of the property in manner to
avoid the growth of mold and shall hold Contractor harmless.
11 • Contractor is not responsible for adequacy of drainage or ponding on the roof due to the existing structure.
12• If material has to be reordered or restocked because of a cancellation by the customer, there will be a RESTOCKING FEE equal to twenty-
five (25%) of the contract price.
13. Contractor shall be entitled to file a lien or claim in the event that payment to Contractor is not made.
14. If a dispute shall arise between Contractor and Customer with respect to any matters or questions arising out of or relating to this
Agreement or breach thereof, such dispute, other than collection matters which may be handled through arbitration or normal collection procedures,
shall be decided by arbitration administered by and in accordance with the construction Industry Arbitration Rules of the American Arbitration
Association and mush be initiated no later than two (2) years after Contractor performed the roof installation. This Agreement to arbitrate shall be
specifically enforceable under the prevailing arbitration law. The award rendered by the arbitrators shall be final, and judgment may be entered upon
it in any Court having jurisdiction thereof.
15. If any provision of this contract should be held to be invalid or unenforceable, the validity and enforceability of the remaining provisions of
the contract shall not be affected thereby.
16. The maximum liability for the Contractor shall be the original cost of labor and materials for the repair which customer agrees shall be a
liquidated sum, under any event of default of Contractor herein.
17. THIS CONTRACT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED
THE ENTIRE CONTRACT BY THE PARTIES.
"t- 0.
i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line \
(303) 235-2855 Office • (303) 237-8929 Fax
'1
INSPECTION NOTICE
Inspection Type:
Job Address: 1 �"
Permit Number: % j
❑ No one available for inspection: Time (1, - .S(� AM!'PM
Re -Inspection required: Yes (No
When corrections have been made, call for re -inspection at 303-234-5933
Date:"c?,5' /7 -Inspector:
DO NOT REMOVE THIS NOTICE
I i CITY -OF WHEAT RIDGE
_:�9rBuilding Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8828 Fax
INSPECTION NOTICE
Inspection Type:A�Vb
Job Address: 370i 1�el1541V �-('-
Permit Number: 30/70 5671
❑ No one available for inspection: Time _; AM/PM,
Re -Inspection required: Yes =.Nom"
When corrections have been made, call for re -inspection at 303-234-
Da/7•f�)�5933
DO NOT REMOVE THIS NOTICE
L
�s l skCT1014 RECORD=�
30) 37�11115or �47 INSPECTION REQUEST LINE: (303) 234-5933
r��'
Inspections will not be performed unless this card is posted on the project site.
Call the inspection request line before 11:59 p.m. to receive an inspection the following business day.**
Inspector Must Sign ALL Spaces pertinent to this project
Wall Sheathing
Foundation Inspections Date
Inspector Comments
Initials
Pier
Concrete Encased Ground (CEG)
Lath /Wall Tie
Foundation / P.E. Letter
Rough Electric'
nn Alnf Pniir [_nnrrafa Prinr Tn Annrnvnl [)t I hP AhOVe Inspections
Underground/Slab Inspections Date Inspector Comments
Initials
Electrical
Sewer Service
Plumbing
nn Ne -it Cnvar [I nriprnrnimell nr 6PInw/In-Slah Work Prior 10 ADoroval UT I ne ADove Inspections
Rough Inspections
Date
Inspector
Initials
Comments
Wall Sheathing
Mid -Roof
Lath /Wall Tie
Rough Electric'
Rough Plumbing/Gas Line
Rough Mechanical
Rough Framing
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.
Fire Inspection / Fire Protection Dist.
Final Electrical
Final Plumbing
Final Mechanical
Roof
5
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 rough Inspections are compieteo Trom the rire ulstrici anu eiectricai low vortaye
by the Building Division.
"For Inspection Time Window Requests - Please email insptimerequest(d�ci.wheatridge.co.us by 8:00 A.M. the day of the
inspection with the property address in the subject line of the email.
Occupancy Is Not Permitted Until A Certificate of Occupancy Is Issued
Protect This Card From The Weather
A i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
_.A!��(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: �, C
Job Address: Li 3o ] 4
Permit Number: J. c>>
1
-N. V
O No one available for inspec ion: Time s -Z ty/PM
Re -Inspection required: Yes
*When corrections have been made,, "11 for re -inspection at 303-234-5933
Date: I Inspe
DO NOT REMOVE THIS NOTICE
A i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: i D
Job Address: J e 1 ► a }- _
Permit Number:
❑ No one available for inspection: Time (� �m/PM
Re -Inspection required: Yes (lol
*When corrections have been made, call for re -inspection at 303-234-5933
Date
In ector:
DO NOT REMOVE THIS NOTICE
ullcfing In to e +c+ D/vfslart
7CtaJ Vtf. 2g e,;iVSRldge, CO 87133
Office: 3013-235-2855 * ,x: 3013-237.8929 Marr Review
Inspection Line: 303-234-5933
Building r it Application
LO
P 0-0
Property Owner Emaik
Mallino Address: (if different than property address)
Address:
City, State, i
Contractor- 12,
Contractors City License M. 6q6q6 P,tlone..
Con too
Sub Contractors-,
Electrical: Plumbing: Mechanical:
W.R, City License # WR City License # WR City License
Other City Licensed Sub: Other City Licensed Sub:
City License # City License
Complete all information +gin BOTH sides of this form
: rt # i.. � • air rt .:: !. . .: • ! + „
Amps Squares Other