BUILDING Az / 1O 0 2tl 7
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Area a qw, esiel nuM InR« car see Rand Courny Ce P smbek:g
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010 1efe Pc110� www.IW..t
.A( Mental BuIMlna and Trades
Owner's Name: /( Pi l5 o A vS� pa
Site Address:pl'1 Co 1_.. .. ; v.• 0 / Phone: — 3S )
Directions to j• • . from ull� r Z�QE� r._ . li s ,
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Subdvlelon: L l a""c'
Description of Proposed Work: #Bedrooms:
Heated SF Unheated SF Finished Rec Room? Crawl Space () Stab ( )
k Pant
Bulldbrpcontractors Company Name Telephone • •
adds . � d k
Llanp
U MuM sip' 11 A cut second pen
Desalpdon at Illior �11 • dam r^* . ?.. Molt Yinffi0
I elsOn i N-Y so 'iv 1 G O- 7:3 0.
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E lectrical Contractors Company Name Telephone 7
A�FK9fa. �/z�"
License tl
Signature of Of0osr(a) of Corporation
iiillblidanagagglijegatkill
Dsswlptlon al ft*
Mediate' Contractors Company Name Telephone
•
Address License /
SIgnstu e a MS) of Capordwt
amddasammiaga
Description of Illtdi a Baths
Plumbing Contractors Company Name Telephone
Address License 0
Signature of OMcer(s) of Corporation
inageonaminftconn
lnsulaton Contractor. Company Neme & Address Telephone
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Homeowners Applying to Build Their Own Home
Pleas amt lie keening passes Pais e Pre Ta nleirt ws dardne r you qua ter pens w'dw Owns. Ea . , L...
Questionnaire per 0.8. 87 -14 Regulations as to Issue of Building Permits (yarns ev.eebla upon mowaq
1. Do you own the land on which this budding will be constructed? yes _ no
2. Have you hired or Intend to hire an Indlvdual to superintend and manage construction of the
project? _ yes _ no
3. Do you intend to directly control & supervise construction activities? _ yes _ no
4. Do you intend to schedule, contract, or directly pay for all phases of construction work to be
done?
yes _ no
S. Do you Intend to personally occupy the building for at bast 12 consecutive months folboring
completion of consbucllon and do you understand that If you do not do eo, It creates the
presumption wider law that you fraudulently secured the penult?
— yes __ no
1 herby owl" Ilse I haw the ado* to mats necessity applorkse, That the application Is correct
end fhb the cars0u it en ell content to the remaking in the Buid% 0sabbal, Plumbing and
Medal osl oaks Indite Hamel Comfy atone t ems the inlbnnslon an do above
cov*aC s Is sanest as Mown 10 me and if urges coat Mains listed c. actor, sib
flirter of berets, bulling and bads pbrr
isnhl Health changes or use
changes, I Catt 1 b my responsibility ti
r to nay the Hanes Candy � Pe.Nti DePabnent of
W IRED MIST PEES - 8 Months to 2 yews pwmk rswbwe tee b $150.00. Alter 2
Is s pe anent flee ached*. Yams re -lees fee
97 Oar- 6 - aP —i O
st o s) of Carpaaaan Date
Affidavit for Sues Compensation N.C.O.S. 87 -14
undersigned Thundersigned epp/care tier
Genera Cantreebr Own., OAcerlip nt dew Cantracta or Own.,
Do hereby li
b in rive our �f parson* r par. mis). corpeaUa4N �
perq wok
ir
set ✓fns tine (3) or more emplysas and has cabbed worker compsns aor Mureroe to oat teem.
Has one (1) or more wSoare dfls) srd hie obbbad worker Dom ensallon kanice to corer
there.
_ Has one (1) or more wboonbsdorr(q Mr has their own poky of woken' compensation Surma
covering thennnMes.
_ Has no mars than two (2) employees and no suaoonbsorae.
Mlle waking on the project for Mich Ills permit Is sought It is understood that the Central Permitting
to Issue= of pre a at � erne diming the permitted work from worker's compensation c corporation pricy
carrying out the welt. cry Pew, then ., eaptlan
Com or
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