11B FILLMORE - BPA-07-647 CITY O
PUBLIC:PROPERTY
DEPr1RTNIENT
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AP "LIGATION ORTMREP" BEN YA ON :CONSTRUCTION
DEMOLITION. OR.0 . GE:OOVSE =,,000444CY..FOR AN3t`'E.Jgslm
STRUCTURE;OR:BUILDING
1`.0 SITE INFORMATION
4ccationName:
Property OFWOO. �1 ------
Q Rip. r pp. p i vy10r2, Sc,(R-vv\ 0t470
Properly b bcated?ln a;Conservation Ares YM - Historic Obtrict YM ... -
ip
20 OWNERSHIP'INFOR. �TION
2:1 owner of Lanot
Name: c u0.� e&RYt
Address:
Teieptxxte
3.0 COMPLETE THIS SECTION,FOR-UVORK IN EYI++TrN�"BOIL"DINCa8=ONLY
Addition Existing'
Renovation Number of Stories Renovated'
Change in'Use NeW
Demolition Exi§tlhg . "
Approximate year of Area per floor,(sf) Renovated
construction or renovation
of existing building New,
9aef Description of Proposed Work:
P-r-q(ac " �;Pe . ��� L _) Knox
- 77 - -- --
Mail Perrnitto: l 6 io T(-ewe on c�� , tMle rose VVl!�, 0 21 b
What is.the current use of-thenBuilding? _ .
Mate!ial'of Building?. ll�ool9C W dwelling;how maI11f its?
WIN the-Building°Conform to Law?,
Architect's Name ( .)
Address•and,Phone,
Medmleis Name
Address and'Ptione -
Construction Supervisors license# HIC Registration#
s; Permit F"Calculation
Estimated,Cost•of Project S_3.s�=—
Permit Fee S Estimated Cost X-S71$'l O00'Reaidentlal
--_----- --- . --- - -- t3Cmated CosYX'Sft/Si000 F.eininerc'•ol' - - ----
AnAddkionai S5.00 is add-.-as'an
Administrative charge;
Make sure that all lbolds are•properly andtlegibly"written to avoid dela"s insproceit§ing:
The undersigned does,hereby:apply forsaSuilding Perrnit'to build to the abovb-stated:
specifications. Slgned under penaHyof.'perjury
x_at:± �' �_
Date t T I'i-0`1.
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