1D HART WAY - BUILDING INSPECTION What is the current use of the Building?
Material of Building? if dwelling. haw many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone 2
Mechanic's Name
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Address and Phone /9 "
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Construction Supervisors License# HIC Registration#
Estimated Cost of Project i ai3�a Permit Fee Cak, Won
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to bui to the above stated
specifications. Signed under penalty of perjury
Date ilk 3 v 7
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MAYOR 130 WWUNcyrw hrwEE'r 0 SALLw%1AStAoILStI'iS 01970
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APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING_
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: a, Building:
Property Address: /—,Q ry,r-7 4 / e, l
Property Is located in a;Conservation Area YM HWbft District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: >7$ 3 S. 1V?/
3.0 COMPLETE THIS SECTION FOR WORK IN FY1l3i1NfS BUILDINGS ONLY
Addition E
Renovation Number of Stories
Change in Use y Demolition
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Sri& Description of Proposed Work:
-- - - Mail Permit to: