5D GRISWOLD DR - BUILDING INSPECTION PUBLIC PROPERTY
DEPARTMEIINT
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APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1A SITE INFORMATION
Location Name: ,..qn P--t',,4t Building: S b
property Is located In a;Conservation Ares YIN Historic Diatrid YIN
2.0 OWNERSHIP INFORMATION
2.i Owner of Land
Name:
Address:
sc
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN E7tlS11bla BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use 7 New
Demolition Existing
Approximate year of Area per. floor (sf) Renovated
construction or renovation
of existing building New
ELdd Description of Proposed Work:
-------Mail Permit to: k4o n <./o
What is the current use of the Building?
Material of Building? If dwelling.how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name` tQ r y9 bI,I6 i7 79�1
Address and Phone �'
Mechanles Name
Address and Phone
Constriction Supervisors License 0 HIC Registration#
Estimated Cost of Projed S Permit Fee Calculation
Permit Fee i Estimated Cost X$71$1000 Residential
--- - - -- - -- — --- Estimated Cost X$11/S1000 Commercial-=- ---- -- - - -
An Additional S5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays In processing.
undersigned does hereby apply for a Building Permit to build to the above stated
The ig
specifications. Signed under penalty of perjury
Date
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