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21420 Nain Street NE o <br /> 1~<et,~-~ .......... P.O, Bo, ,00 $,gn Per,,i~ N~.. ...................... <br /> <br /> ., <br /> <br /> .............. <br />Plans By: ~ ~CI~ Ph.: Address: .~.~ City 5ta~e~.Zip ...... <br /> <br />= H~p No.= i Zone= I Zona Change: ~ pl~,= ~ Conditional Use~ [ Variance/kdjo i Occupancy: ~ Type o~ ConsWuct~oni <br /> <br />: <br /> <br />AREA OF <br /> <br /> T .... ~*,~ P Truss/stlck.~' ' Valuahon' ............................. ' <br /> <br />~istorlc Re~[ev Board Cha~raan ............ Da~e.. ................ Si~n Pere/[ ~ee: $ ....... . ..... <br />City Offtct,t <br /> <br /> ( <br /> (~ I ,. a registered builder O~ [g[~L[[[~: ~.~- <br /> ) [ al the authorized representative of 4 registered builder <br /> ) The v0rk vHl be perforeed by a registered buHder <br /> ( ) 0t)~e~ (Please Specify) <br />I have read th~s application Jn its entirety and c?~tfy the stated ~nforeatton ~5 true.and correct to the best of ly knowledge. <br />~L[6~[ ~{l[: Driveway and~?a~ns~ns ~equi~ by Public Korkst (503) 678 12a3 <br />SIGNATORE'OF APPLICANT _', ..... .'~ .~ ........ , <br /> <br />t[~A~K~: .............. ~ .............................................................................................................. <br /> <br /> <br />