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3 EVERETT RD - BUILDING PERMIT APP EIl'StOF LEry PUBLIC PROPERTY DEPARTMENT �u+ruisro�socx�. S,We �:m�s•ss•r�m�.a9w D . �.o atrt INFORMATION •- . Loca*m Noma Building - Proparty Y kxwbd In a;C,a,aarvatlon Area YM�_HR9orfa t7lstrlot YM 12.0 OWNERSHIP INFORMATION 9.1 Owner of f.arul Address. Tw"*Ww, 3.0 COMPL M THIS SECTION FOR WORK IN fEXl Mks BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change In Use Now Demolition E)ds&g Approximate year of Area per floor(at) Renovated construction or renovation Of existing building Now Brill Description of Proposed Work: AIJ /dD�iTion/� k /NT�21vc 12h/w�ia�s --- -- ---Mail Permit to: r2 VA 45 use at t+.guietnf? - , What is do anrent . itdwOM I&how am'y'u'iRs't Materisi of Bin i g? � Asbeatos4 a%(' . . . Will to SOAV O Conf&M 10 Law? Mgdwdes VGA ZO-�Wi��-y Name Canso Supervises License f z2dl6 7 HIC RepMtratlon dlOdMW Estmatad Cost Of f //© ooc. Pama Fee C Permit Fee f Estimated Cad X f7/f1000 Residential Eattrtatad Cost X f41/f10o6 Cartwnards�--_.. An AdMUWW f6A0 is added as an Adminiatradve dwarSe. Make aura that aY tieids are propary and ebb`"ran to avoid deiaya in proeesslnp. The wwJer Wad does iwreby apply for a SOO*Permit to tte apaaW.lone. Signed under PWAIV Of Perry Dat0 /6 io 0 0 9