1C HALSEY WAY - BUILDING INSPECTION EITrOFg -
PUBLIC PROPERTY
DEPARTMENT r�
MAYaa I20 WASHING"SME"• ••xW%(ASSADiIStTI301970
APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building / C
Property Address:-
property Is located in a;Conservation Area YIN H'atario DistrkA YIN
2.0 OWNERSHIP INFORMATION
7.1 Owner of Land
Name:
Address:
G !l w
Telephone: 07
3.0 COMPLETE THIS SECTION FOR WORK IN EYISItdG 13UILDINGS ONLY
Addition Existing
Renovation L--/ Number ofStories Renovated ram Change in Use -- New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brie[ Description of Proposed Work:
- - - -
Mail Permit to: P0 X of c:) Zrd
What is the current use of the Building?
Material of Building? If dwelling,how many units?
Will the Building Conform to Law? Asbestos?
Archited's Name S/O `��' `j7.7 9
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License 0 HIC Registration#
Estimated Cod of Projed s Permit Fee CalcuMm
Permit Fee s Estimated Cost X$71$1000 Residential
Estimated cost X$I I/sl000 Corm wciat-----_..
An Additional $5.00 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 X
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