HomeMy WebLinkAboutBLD1991-00877 •
SQUARE FOOTAGE p! , rr���� PRINCIPLE TYPE OF HEATING FUEL
MAIN FLOOR ( �-L�2�{J
ELECTRICITY ❑ OIL
2ND FLOOR -- ,_-----I1 2-73 ❑ WOODSTOVE 0 GAS
3RD FLOOR {�. ❑ HEAT PUMP ❑ OTHER
HTD BASEMENT i /-!32}:
UNHTD BASEMENT
DECKS PRINCIPLE TYPE OF FRAME
CARPORT
GARAGE ❑ WOOD ❑ MASONRY
COMMERCIAL 0 MANUFACTURED 0 OTHER
INDUSTRIAL ❑ STRUCTURAL STEEL
TOTAL VALUATION 1-79_0280 OR ESTIMATED COST
TYPE OF SEWAGE DISPOSAL:
❑ SEWER INDIVIDUAL SEPTIC
TYPE OF WATER SUPPLY:
❑ PUBLIC ❑ PRIVATE ❑ COMMUNITY WELL INDIVIDUAL WELL
NUMBER OF EXISTING BEDROOMS NUMBER OF EXISTING BATHROOMS
NUMBER OF PROPOSED BEDROOMS _3_-- NUMBER OF PROPOSED BATHROOMS
TOTAL NUMBER OF BEDROOMS TOTAL NUMBER OF BATHROOMS
NAME OF ADJACENT BODY OF WATER
BANK HEIGHT SETBACK
/XeSIGNATUR / /
DATE / /O BASE FEE 90.
PLAN CHECK el. D RECEIPT #
STATE SURCHARGE 1 OS
T &'‘Z • D TOT
AL CASH/CHECK #
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