HomeMy WebLinkAboutBLD1991-00838 SQUARE FOOTAGE 74: PRINCIPLE TYPE OF HEATING FUEL
d X MAIN FLOOR / 2[ == oec - ❑ ELECTRICITY 0 OIL
2ND FLOOR 0 WOODSTOVE ,.--ttni< GAS
3RD FLOOR ❑ HEAT PUMP 0 OTHER
HTD BASEMENT
UNHTD BASEMENT
DECKS PRINCIPLE TYPE OF FRAME
CARPORT WOOD ❑ MASONRY
GARAGE MANUFACTURED ❑ OTHER
COMMERCIAL ❑ STRUCTURAL STEEL
INDUSTRIAL
TOTAL VALUATION OR ESTIMATED COST DQ
)
TYPE OF SEWAGE DISP-00
ir
4 SEWER INDIVIDUAL SEPTIC
IA:
TYPE OF WATER SUPPLY:
❑ PUBLIC ❑ PRIVATE ❑ COMMUNITY WELL INDIVIDUAL WELL
NUMBER OF EXISTING BEDROOMS NUMBER OF EXISTING BATHROOMS
NUMBER OF PROPOSED BEDROOMS NUMBER OF PROPOSED BATHROOMS
TOTAL NUMBER OF BEDROOMS TOTAL NUMBER OF BATHROOMS
NAME OF ADJACENT BODY OF WATER
BANK HEIGHT SETBACK
SIGNATU GZ %'=�(/L - DATE / /7 �!9/
BASE FEE p? ,t
/
7
PLAN CHECK RECEIPT # V / 3 3
/0
STATE SURCHARGE 1('L.,
4/
TOTAL -7 (.0 '11 CASH/CHECK #____
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