9C FILLMORE RD - BUILDING INSPECTION (2) What is the current use of the Building?
Material of Building? If dwelling. how many units?
Will the Building
uildl Conform to Law? Asbestos?
Architect's Name ( ) ��—� �[3 C>O
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project S Permit Fee C"lation
Permit Fee i Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrable 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
/410"
specifications. Signed under penalty of perjury
Date
N
O
Y/
I ` O
a
CL
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1
-- EITY-OFSALEM --
�3s, PUBLIC PROPERTY
DEPIARTMEINT
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MAYOR 130 WASMN(TON!17Err 0
SAL&A4 N(.AStAaHtstl'1S 01970
TM;970-7ii95"•Fnx:971-740-98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION, OR CAANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 31TE INFORMATION
Location Name: Building:
Property Address: Q
Property is located in a;Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: 9 n
Telephone: C,?-78� ---7 7 -1 4?1706
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 (sf) Renovated
construction or renovation
of existing building New
&ieff�D�esscri�ptiion of Proposed Work:
Mail Permit to: _ 4.c