2B STILLWELL DR - BUILDING INSPECTION (2) EI"I`�OFg�LE� --
PUBLIC�'ROPERTY
�7 DEPARTbIF.�iT
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MAros
170 WtitMN=W b"MM 0 SJU04 MAZAGMShTiS 01970
M-9''a.745-95"♦FAX 9711.740.96"
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EMS-TING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 050,k «-r.,K. Building:
cZ ` 'Q S:t-�2�we� CIA-
Properly is located in a:Conservation Area Y/N HIstorla Disad Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: -1 ej L _ � 1
3.000MPLETE THIS SECTION FOR WORK IN EXIST l3 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use y New
Demolition Existing
Approximate year of Area per Floor (so Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work:
&W Lie , X&(-) , ,
___Mail Permit to:
what is the current use of the Building? t
Material of Building? If dwelling.how many units?--
? Asbestos?
Conform to Law
win the Building _
Archited's Name
Address and Phone— oy c/96�
Meahanles Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Projed s. a Permit Fee(Calculation
Permit Fee s Estimated Cost x s7/s1000 Residential
— Estimated cost x sm$1000 Commercial----An Additional$5.00 is added as an
Administrative charge.
Make sure that all flelds are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of perjury X ^� —
Date y' �/- a` j
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