BAKERS ISLAND - BUILDING INSPECTION (32) GITY"O1' JL1L.E`\i
PUBLIC PROPERTY S
DEPAR-MI&NT
,u..or�nsv ouscou.
1%U1K wssAau:se„s uj97o
nL M. 71S-9S".FAX 97LUO9srs
APPLICATION FOR THE REPAIR. RENOVATInN CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR FOR ANV EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION '
Location Name: R- k nee Cotfo e. Building:
Address: toff
Property is' in a;Conservation Arse YIN No Hlatorb DlsMct Y/N Al o
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: C61-5 -o tief
Address P+� Qdx 55 �'ta �1e�� �a MA Fy�gyy
Telepttone:
3.0 COMPLETE THIS SECTION FOR WORK IN EYISTWo BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing ci D D
Approximate year of Area per floor (sf) Renovated
Construction or renovation 1194(0
of existing building New
8dd Description of Proposed Work:
Repa:,r c. j e replan¢ vJ 1nc�ows o.� �ao�t S,Ra a� cmi}�e
1 1
i
— - - Mail Permit to:
What is the current use of the Building? k i v ' n 1 5 a c e
Fr..re It dwelling.how many units?
Material Of Building? Woo Asbestos? A�oi��eiy None
"I,the Building Conform to law?
Architect's Name ( )
Address and Phone
Mechanic's Name
Address and Phone HIC Registration S
Construction Superviaors License
E .3stimated Cost of Projed i nop_ puma Fed Calailatlon
' Estimated Cost X$7/S1000 Residential
Permit Fee= aCo
A��.e Estimated Cost X i1 Vao00 GammercisL------_
µa.A Av o Q"t An Addkny $5.0o is added as an
o+be.r 3+���°^°3 Administrative charge.ty nqG
S
Male sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building,P-omit to build to the above stated
specifications. Signed under penalty of perjury
Date 7 -
by
a v e
o