29-090 (4) VIII. ZONING PLAN EXAMINERS NOTES
DISTRICT A +
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
IX. SITE OR PLOT PLAN — For Applicant Use
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BOCA FORM APESP — 669 C1969 BUILDING OFFICIALS & CODE ADMINISTRATORS INTERNATIONAL, INC.
IV. IDENTIFICATION — To be completed by all applicants
A. Name Mailing address — Number, street, city, and State ZIP code Tel. No.
Owner or
Lessee
r Builder's G
2. License No.
Contractor
3.
Architect or
Engineer
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to
make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction.
Signature of applicant Address Application date
00 NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD — For office use
Plans Review Re uired Check Plan Review Date Plans By Date Plans By Notes
9 Fee Started Approved
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Dote Date
Permit or Approval Check Obtained Number By Permit or Approval Check Obtained Number By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use Group
Permit issued 19
Fire Grading
Building
Permit Fee $ /27 ev Live Loading
Occupancy Load
Certificate of Occupancy
A ed by:
Drain Tile
Plan Review Fee
TITLE
t
NOTES and Data — (For department use)
-r
APPLICATION FOR
PLAN EXAMINATION AND
— ® BUILDING PERMIT
z
IMPORTANT — Applicant to complete all items in sections: 1, 11, 111, IV, and IX. O
lL�
ING
//
I• AT (LOCATION) ( •'�••' ,r ��)� 2 DIOSTR CT/��rr^' R'
LOCATION (NO.) (STREET)
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
N
II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D
A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking" most recent use m
m
1 ❑ New building Residential Nonresidential
2 Addition(If residential, enter number 12 One family 18 ❑ Amusement, recreational
of new housing units added, if any,
in Part D, 13) 13 ❑ Two or more family — Enter 19 ❑ Church, other religious
number of units— — — —
3 ❑ Alteration (See 2 above) 20❑ Industrial
14 ❑ Transient hotel, motel, 21 ❑ Parking garage
4 ❑ Repair, replacement or dormitory — Enter number 22 ❑ Service station, repair garage
5 ❑ Wrecking (If multifamily residential, of units ——————— — --�
enter number of units in building in 15 ❑ Garage 23 ❑ Hospital, institutional
Part D, 13) ❑
16 Carport 24 ❑ Office, bank, professional
6 ❑ Moving (relocation) 2 ❑
17 ❑ Other — SpeciJy 5 Public utility
7 ❑ Foundation only
r 26 ❑ School, library, other educational
B. OWNERSHIP r�rLG� l� 27 ❑ Stores, mercantile
8 Private (individual, corporation,
28 ❑ Tanks, towers
nonprofit institution, etc.) k, — 29 ❑ Other — Specify
9 ❑ Public (Federal, State, or
local government)
C. COST (Omit cents) Nonresidential — Describe in detail proposed use of buildings, e.g., food
processing plant, machine shop, laundry building at hospital, elementary
10. Cost of improvement•,•••••.•....... 00 school, secondary school, college, parochial school, parking garage for,
department store, rental office building, office building at industrial plant.
To be installed but not included If use of existing building is being changed,enter proposed use.
in the above cost
a. Electrical.....................
b. Plumbing .....................
c. Heating, air conditioning..........
d. Other (elevator, etc.).............
11. TOTAL COST OF IMPROVEMENT ;,
III. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L;
for wrecking, complete only Part J, for all others skip to IV.
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS l
Masonry (wall bearing) 40 Public or private company 48. Number of stories.............
30
31 [Wood frame 41 n Private (septic tank, etc.) 49. Total square feet floor Dora, `C.f�j'
all Floors, based on exterior
32 ❑ Structural steel dimensions .....................
33 ❑ Reinforced concrete H. TYPE OF WATER SUPPLY
34 ❑ Other — Specify 42 Public or private company 50. Total land area, sq. ft. ...........
43� Private (well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
51. Enclosed ......................
F. PRINCIPAL TYPE OF HEATING FUEL I. YPE OF MECHANICAL
35 Gas Wil ere be central air 52. Outdoors........................
36 Oil condition ?
L. RESIDENTIAL BUILDINGS ONLY
37 ❑ Electricity 44 ❑ Yes No 53. Number of bedrooms..............
38 ❑ Coal
39❑ Other — Specify Will there an elevator? Full...
54. Number of 4
46 ❑ Yes 47 ❑ No bathrooms
Partial./....
V.A
M
Department of Building Inspections
212 Main Stree° BUILDING ;_ /g oo all Y/v
Noraon, Ma: olobo PERMIT 0a
' a
29 - 90
VALIDATION
DATE .lima 1Q. 19 Al PERMIT NO. 300
APPLICANT Roboxt rS- Vx-nklln ADDRESS 'I[) Rrip,3jMnd nriya
(NO.) (STREET) (CONTR'S LICENSE)
NUMBER OF
PERMIT TO (� ) STORY_ Srxeered in in DWELLING UNITS 1 _
TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
AT (LOCATION) 10 Bri Prwnnd Drives ZONING
DISTRICT URA
(NO.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
Addition
)(DC
XKXK IS TO BE 14 FT. WIDE BY 16 FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: Addition of screened-inP add
AREA OR PERMIT
VOLUME ESTIMATED COST $ 27 3OO FEE
(CUBIC/SQUARE FEET)
OWNER J.obert Franklin BUIL IN
ADDRESS 30 B-1-Arwood Driven-Northam ton, Mn_ Q1060 BY /Kilf',(elz
WHITE - FILE COPY . GREEN - FIELD COPY • CANARY - APPLICANT COPY • PINK ASSESSORS COPY