1 KERNWOOD ST - BPA CITY-OF"gALEIN -
PUBLIC PROPERTY
DEPARTINI&NT
1:I�WFJL6Y OR45(:W3. ����v
%IAWM 130 WA"NGWW!bMFX7
S•—`'-�4 XAttAUtl:Shl'IS 01970
TM_919-74S-9S9S•FNC 97b740.9&6
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION e f h Com l�I
Location Norms: Kern D 5 Building:
-- — Property Address-- - ------ -- - - -------et h��rc
filer - --
1
Property Is located in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Kern w o (.,�;. 1, S
Address: I !<<,,wa y S
Sa
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
8del Description of Proposed Work:
5- 4�L N2w 4.in 0 ./' v✓.P✓' V'✓/�c'f9/1 C.�a,h /
C
Mail Permit to: --
STM --
What is the current use of the Building?
lr� cT vnf C1-5 h.2;J-�e
Material of Building? If dwelling.how many un'lts?
Will the Building Conform to Law? Asbestos?
Archited's Name
Address and Phone t
Mechanic's Name
Address and Phone
Constriction Supervisors License 0 n `� HIC Registration#
Estimated Cost of Project$ �, Permit Fee Cakxriation
Permit Fee$ Estimated Cost X$71$1000 Residential
– Estimated Cost X$I V$I000 Commercial-
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—' �–
Date
J N
0
x
0