5 CIRCLE HILL RD - BUILDING PERMIT APP CITY OF-SA= _.
PUBLIC PROPERTY
DEPARTMENT
/:I�NFFJL6Y D�LS[IMJ.
Naval 130 WASMNGnW$MFM• '�iur,NwsuaI.strs 01970
Tn--97 US-MS*FNC 976740-9W
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: o r r, Building:
Property
6- 6PIP
Property is located In a:Conservation Area YIN Historic District YIN A_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land r t
Name:
Address: n „
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIST1UG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of . /9C Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: --
What is the current use of the wlding?
"� If�! ailing.how many un'RsT
Material of Building? l �
WIN the Building Confornyto Law? Asbestos? -
ArchiteG's Name
Address and Phone ( )
Mechanic's Name
Address and phone ��/
Constnrctlon Supervisors License# D 6G HIC Registration#
Estimated Cost of Project S/G�d�, . Pamdt Fee Calculadw
Permit Fee S G Estimated Cost X$71$1000 Residential
Estimated Cost X$11/$1000 Commerclal
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 rt the abovA stated
specifications. Signed under penally of perjury
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