5C GRISWOLD DR - BUILDING INSPECTION PUBLIC PROPERTY
DEPARTMENT
�rAYa 130 WA91,NaM*!kM= S.LLUiY,.MAgAIX{;Sh'114 01970
To-97a.71S-9M•FA=M740.9W
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Nana: Building; 5 G
- Property Address: C ^ ' �
Property is located in a.Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
'�—
Telephone: no
3.0 COMPLETE THIS SECTION FOR WORK IN EnS11HO BUILDINGS ONLY
Addition Existing
Renovation r/ 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
Brief Description of Proposed Work:
—— - ----Mail Permit to: /,�'®
What is the current use of the Building?
Material of Building? It dwelling,how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name J�
Address and Phone
G �S� Siam c>tcic�o �JZ7
Mechanic's Name
Address and Phone
Construction Supervisors License 0 HIC Registration 0
Estimated Cost of Proled$�
Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/111000 Residential
....... . ____ _.. -_.___- Estimated CostX$11/411000 Commerola4-------- -An Additional $6.00 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
of
n
0
\ y
S s