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3. Job Address
5. City
6. State
7. Zip
11. Property Owner
12. Last Name
14. Address1
16. Address2
18. City
19. State
20. Zip
24. Contractor
25. Last Name
27. Address1
29. Address2
31. City
32. State
33. Zip
37. I hereby certify that I have examined and read this permit. All provisions of this ordinance will be complied with whether specified herein or not. Any person, firm, corporation, or agent thereof who violates or otherwise fails to comply with Section 78-531 may be found guilty of a misdemeanor and accessed a fine of up to $500 per day for each such violation.
39. Signature of Owner or Authorized Agent
40. Date
    Date
42. Permit Requirements
    Requirements (PDF)
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44. 1. Receive an email copy of this form.
45. Email address

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46. Submit

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