3A FILLMORE RD - BUILDING PERMIT APP (002) Crry-OF-
PUBLIC PROPERTY
DEPARTNE&NT
a�a�7nsr o.�sciy. /�L�--moo
&vuk%(.li6Ad&StT15 Ot970
147E MUS-MS•FAx 97L740.gW
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 Building:
- - Property Address1��cn c ---- - ---
properly is located Ina;Conservation Ares Y/N N-/ HlsWdc DIsMd YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Lanai
Name: H
Address:
Telephone: 2__7.f �•�
3.0 COMPLETE THIS SECTION FOR WORK IN EYIBIMQ BUILDINGS ONLY
Addition Existing
Renovation >< Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building I New
B&J Description of Proposed Work:
2L
---- ----M21l PBRTIIt to: 1A, �//7. hn� �U' A v i3P� � )7y j�& � Uf 7
What is the current use of the Building?
Material of Building? If dwelling.how many unitsT
will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone l
Mechanies Name ✓� C h irn n ea r c
Address and Phone
Construction Supervisors Ucenssee S HIC Registration 0
Estimated Cost of Project Permit Fee Calculation
Permit Fee= Estimated Cost X$71$1000 Residential
Estimated CostX i41/$1000 Commwclal -------- - - _ _ - -
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 penalty of perjury
Date
N
a
�. •s II C V�° y 3
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