6D RUSSELL DR - BUILDING INSPECTION EI`r _FSAL --
PUBLIC PROPERTY
DEPARTMENT
SIAYot 130 WAL1,dGToN NmEET SM.LK J(.LcsnUu;st1'IS 01970
TEL 97&74S-959S*Fex:97&740.96"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1 A SITE INFORMATION
Location Name: ;C iG p , PARK- Building: 6- 0
Property Address: -- e l
Property is located in a; Conservation Area Y/N— A J Historic District Y/N �b/
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: `1 p
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Z_� Number off Stories Renovated
Change in Use L/ New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
old -F,•Q-le s L) .s re.,u� /N6T,411
.New S `LPeP-toR 55 site
_u;6
Mail Permit to; 1v,.4 01 9 ef6
What is the current use of the Building?
Material of Building? If dwelling. how many units?
Will the Building Conform to Law? Asbestos? .n
Architect's Name
Address and Phone
Mechanic's Name Z/S e 0 6i M 'U�`)--��—Z`—� 5 9-7-7
Address and Phone k'E>o 13oX N o'+y f2A4 22� ,,A
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ e�2kPM Permit Fee Calculadon
Permit Fee$ — Estimated Cost X$741000 Residential
Cost X V 141000-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
�P/erm48 /c>
o the above stated
specifications. Signed under penalty of perjury X
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