78 DERBY ST - BUILDING PERMIT APP JACKET PUBLIC PROPERTY
DEPARTMENT
KI.WEJ.EV DUSCA"
MAYOR 130 Wksmmarm pram yuEK NAssAtHLSh'll3 01970
T EL-972-74S-9S9S♦FAx 976740.9"6
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: A h Building:
Property Address:------- - - -
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: � t7wA _
Address: -78- (1 _
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (SO Renovated
construction or renovation
of existing building New
Baef Description of Proposed Work:kc�v-�Vl vat
S `Ql5\'�h S- L ova
Mail Permit to: - --
What is the current use of the Building?
Material of Building? Y�O� U if dwelling,how many units?
Will the Building Conform to Law? 1 e S Asbestos? lU O
Architecrs Name
Address and Phone t
Mechanids Name
Address and Phone
Consbvdion Supervisors License* o�\�o IS HIC Registration#
Estimated Cost of Project$�
Permit Fee Cakxiiatlon
Permit Fee$ Estimated Cost X$71$1000 Residential
--- -. -- -__ — -- Estimated CostX$111S1000 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 Perm
it to the above stated
specifications. Signed under penalty of perjury X
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