021B MARION ROAD - BPA-08-389 9 �
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3`0 CCMPLt"TR.�W SECt-1 "Fid WORK IN E]U�IIJil4,�UILCIt�IGB QNLY "
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Renovation 'IN mber of"Stories ;Renovated
Change in lJss Netiv
Dead idon ;.Ewsting,,.
Approximate yearof" Area per floor=(sf) Rertpvated construcdon or renovation
of eatistmg buiidmgw Nerir
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yyttatis the CUffBfIL U30 0) Sh9 many un
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Material of Building? !—��`� ifdwelling.how many
Conform to Law? Asbestos?
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Will the Building ,
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Address and Phor+a- dlYl ��( U O
Mechanic's Nart+� m � �M� , p 21 Z�
Address and Ptwra l fnI —
Conamwtion Sumvisors Ucense$ CISOI'22 HIC Registration r
Estimated Cost of Projed s a --� Permit Fer Cakx+latla�
C /Permit Foe Estimated Cost X$7IS1000.ResidentW
t fit-
eeun,atsd CostX3„n,000 Cammereia4---
An Additional $5.00 is added as an
Administrative charge.
Make sure that allflelds are properly and legibly written to avoid delays in Processing-
The undersigned does hereby apply`for a.Bullding.PerrnitWbuild too,the above stated
specifications. Signed under penalty of PerlurY
Date
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