2C HART WAY - BUILDING INSPECTION Erntol'-g
PUBLIC PROPERTY
��� DEPARTMENT
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APPLICATION FOR TSS REPAIR. RENOVATiex CONcTrar>< CTIOnr_
DEMOLITION,OR CHANGE OF USL OR OCCUPANCY FOR ANY ljav ING
STRUCTURR OR BUILDING
1.0 SITE INFORMATION
Location Nsrr r Building:
Property Adder--_-�C
Prop ft is located in s;Conservation Are@ YM Historic Obeid YIN
2.0 OWNERSHIP INFORMATION
2.t Owner of Land _
Name: a77V17
Address:
Telephone: — 97 — 05- -K'
3.000MPLETE THIS SECTION FOR WORK IN En@MM BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
The Chimney Guys
--- ------Mail Permit to: - - ---
What is"«,Rene use of the Building? If dwelling.how many unit?
Material of Su"ddIng? Asbestos?
Will"BuBrung Conform to Law?
e Chimney Guys
Amhaeds NanN p ox
Address and Phone 1
Medwrries Name 0
Address and Plane
Conabucllon Supervisors Lieense 0 HIC Reghtrstion 0 -
3� ` Per"Fee Calwlation
Edlmao.d cod of Projed$ , ---
Permit Fee S Esd natsd Cod X:7/51000 Residential
Estimated Cod X S11/:1000 cammareia�------
An Additional :6.00 is added as an
Administrable charge.
Make sure the ati fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply tar a Building Permit to build to a above stated
specification, Signed under penalty of POJury
Date a
I
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