1A NIMITZ WAY - BUILDING INSPECTION CITY-OFS-ALEl —
oZp�"�OG� PUBLIC PROPERTY
DEPARTMENT:
KI?MFIU.EY DRI5CULL �� "
Stnvoa 120 WASHINcmN STaFFC#SnLEer,MAs4nd4:5kTIS 01970
I'm 973-74S-9S9S 0 FAX 978-7449946
APPLICATION FOR THE REPAIR- RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Mcr C r tC Building:
Property Address: /-19 /t�e• vt.�� L✓6—/
property is located in a: Conservation Area YIN d✓ _Hlstori�:District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: L/
Telephone: 9 7 e- 7 3 63
3.0 COMPLETE THIS SECTION FOR WORK IN PY14TING BUILDINGS ONLY
Addition / Existing
Renovation V Number of Stories Renovated
Change in Use / New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation New
of existing building
8d-1 Description of Proposed Work:
.��SL�• digs
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Mail Permit to* 7S/
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i
What is the current use of the Building? G� w
Material of Building? If dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Names
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ 2 x� n Permit Fee Calculation
Permit Fee$ - Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to b '6 to the above stated
specifications. Signed under penalty of perjury
Date l6 d d
of
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