3D FLETCHER WAY - BUILDING INSPECTION (2) EI'I'�OF
7is PUBLIC PROPERTY ��9 ��
DEPr1R'I'1bIENT
VAYM 130 WAwamc+cw birmw•J.ujjW MAnAaa:s►rs 01970
TUL.M. 74S4M•FAV.M74G-9W
APPLICATION FOR THE REPAIR RENOYATION CONSTRUCTION
D&MOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY FMST]NrA
STRUCTURE OR BUILDING-
1.0 SITE INFORMATION
Location Nam ., ,�c� .-K Building: 3 �j
----- Property ------ —
s ao LJL�)�
RvWV Is located In a.Conservation Area Y/N .✓ Historle Dk*M YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: 7
Address` 3 0 �...P��
Telephone: 7,Y✓ 3�� C16�
3.0 COMPLETE THIS SECTION FOR WORK IN EYISII NG BUILDINGS ONLY
Addition Existing
Renovation c/ Number ofStories Renovated
Change in Use 7 Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Scid Description of Proposed Work:
--— ---Mail Permit to: tlo-7 Y /,-6 OP12'o -- - .
What is the current use of the Building?
Material of Building? If dwelling.how many units?
WIN the Building Conform to Law? Asbestos? --
Architect's NartN r J r gee 9 z,? 61, 17i 9OX2�
Address and Phone -
Medwnie's Name
Address and Phone
Construction Supervisors License 0 HIC Registration S
Estimated Cost of Project S-200� Pemdt Fee CalcuMW
Permit Fee a Estimated Cat X$71$1000 ResidentW
Es*m ted Cost s41/:1000 Commerelal--=------
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 jild to the above stated
speciftatlons. Signed under penalty of perjury
Date
M
1t N
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