1 NIGHTINGALE LN - BUILDING INSPECTION PUBLIC PROPERTY
DEPART14iENT
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APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEtifOLITION. OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
— Property-Addresa'(
Property Is located in a;Conservation Area YM Historic District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: tom-
5til¢�, &,4
Telephone: _ �y
3.0 COMPLETE THIS SECTION FOR WORK IN FYICTiucs BUILDINGS ONLY
Addition Existing
Renovation x Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work:
7 � 4t¢w •w� G. w
_-- Mail Permit to:
GL832
What is the current use of the Building?
Material of Building? If dwelling, how many units?--L—
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name , p ?6.2(3- 71 SS
Address and Phone
8 iy�z
Construction Supervisors License# 6�y� T HIC Registration#
Estimated Cost of Project S 10 /f6. Y Permit Fee Calculation
Permit Fee S Estimated Cost X$7/51000 Residential
------ .. - -- — -- -- -..-- Estimated Cost X$11f$1000 Commercia4
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit th v stated
specifications. Signed under penalty of perjury
Date
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