4 CIRCLE HILL RD - BUILDING PERMIT APP EI'P -OF
P'
PUBLIC PROPERTY
DEPARTNI&NT
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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: Building: Z
Property Address:
4 c //-?C
Property Is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: /VI Fi'� N( A,-V C
Address:
5F C; L R
Telephone: 7 — 75L p 76
3.0 COMPLETE THIS SECTION FOR WORK IN EXIRTIBUILDINGSONLY
Addition [���
Renovation r/ Number of Stori
Change in Use %
Demolition v
Approximate year of Area per floor (sconstruction or renovation D �of existing building
Brief Description of Proposed Work:
- - Mail Permit to:
What is the current use of theB`uilding?
Material of Building? W�oO If dwelling,how many unds?�—
IV 6
Will the Building Conform to Law? ---- Asbestos?_
Architect's Name
Address and Phone n uL c7a /J�
Mechanids Name n e aims(
Address and Phone `!filr'
Construction Supery isors Li nse# C ✓�9 3�� HIC Registration#
Estimated Cost of Project i 6 6 Permit Fee Calculation
Estimated
Fee S OU Estimated Cost X$7/i1000 Residential
permitEstimated Cost X$1'*000 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 build to the above stated
specifications. Signed under penally of perjury X_41e
Date
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