6C HALSEY WAY - BUILDING INSPECTION (3) EITStOF
PUBLIC PROPERTY
DEPARTMENT
u.oFxsr DRISC"''
MAYM 130 WAwtricr *A Sneer•SAS 4ASAAat<serrs 01970
•tom:MUS.9MVI•FAe 9711 7+6464
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: fl G k,"9 V 012 V� BUIkMW
Property Address-
Properly Is located In a;Conservation Area Y/N Historic Obvict Y1N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Nam: 4(c51t*P -Okt
Address: /� J
6' IV /IAls�y LoAl.
Telephone: ^
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIINQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use e2 New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Boef Description of Proposed Work:
qq D
-- -- ---Mail Permit to; Po ScrI6 yo`7q 0/c ,r0
what is the currerd use of the Building?
Material of Building? if dwelling.how many units?__
WIN the Building Conform to Law? Asbestos? -
el
ArchiteeCs Name
Address and PhonM
Mechanids Name
Address and Phone
Construction Supervisors Licen
�s
,Ce 0 HIC Registration�
Estimated Cost of Project ice— PwTcA Fee CaleulsNorr
Permit Fee= Estimated Cod X$7151000 Residential
Estimated Cost X$111:1000 Commer;isl------_
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
Date 6—�-Z
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