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IX. SITE OR • Applicant Use
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NOTh and Data — (For department use)
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IV. IDENTIFICATION — To be completed by all applicants
/Name Mailing address – iimbcr, strcc°t, city, carer/ titutc• ZIP code Tel No.
Owner or v /
Lessee
Bui der's
License No.
Contractor
3.
Architect or --
Engineer
1 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 Required Check Plan Review Date Plans By Date Plans By Notes
Fee Started Approved
BUILDING
PLUMBING —! -- � - ---'
MECHANICAL
ELECTRICAL
OTHER S
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS ate Permit or Approval Check Obtained Number By Permit or Approval Check ObtDa ned 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
Permit number 183
Building
Permit issued May 27, 19 �7 _
Building
Permit Fee $ 10.00
Certificate of Occupancy S
Apgx.aved by:
Drain Tile S AJV
Plan Review Fee S`
LOCALLOCAL INSPECTOR
TITLE
Critp of Xort4a p you
� � �IassMCl1nsetfs
T` O£fite of the �ns}lertor of iguiibitigs
APPLICATION FOR
Page J�Plot�_ ZONING PERMIT AND
9 BUILDING PERMIT
IMPORTANT — Applicant to complete all items in sections: I, 11, 111, IV, and IX. p
/ 1�.� ZONING
AT {LOCATION) DISTRICT S •Q(1
I•
LOCATION (NO.) (STREET) _1
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
CA
II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D
m
A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking" most recent use m
1 ❑ New building Residential Nonresidential
2 $4 Addition(it residential, enter number 12 IKOne family 18 ❑ Amusement, recreational
of new housing units added, if any, 13 E:] Two or more fomily - Enter 19 E-] Church, other religious
in Part D, 13) number o units- - - - -->
f 20❑ Industrial
3 ❑ Alteration (See 2 above)
14 ❑ Transient hotel, motel, 21 ❑ Parking garage
40 Repair, replacement or dormitory - Enter number
5 ❑ Wrecking (If multifamily residential, of units ------- - -- 22 ❑ Service station, repair garage
enter number of units in building in 15 Garage 23❑ Hospital, institutional
Part D, 13)
16 Carport 24 D Office, bank, professional
6 Moving (relocation)
17 Other - SpeciJy 25❑ Public utility
7 Foundation only
26 ❑ School, library, other educational
B. OWNERSHIP 27 ❑ Stores, mercantile
8 X Private (individual, corporation, 28 ❑ Tanks, towers
nonprofit institution, etc.) 29❑ Other - Specify
9 ❑ Public (Federal, State, or
Iota{ 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................ 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 Is STJu
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. D
Q
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS m
30❑Masonry (wall bearing) 40 ❑ Public or private company 48• Number of stories................
31 Wood frame 41 Private (septic tank, etc.) 49. Total square feet of floor area, L+t
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 ro
F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL 51. Enclosed ....................... f°
35❑ Gas Will there be central air 52. Outdoors........................ 0
36 ❑ Oil conditioning? L. RESIDENTIAL BUILDINGS ONLY
37 Electricity 44❑ Yes 45 0 No 53. Number of bedrooms..............
38 ❑ Coal
39 ❑ Other - Specify Will there be an elevator? Full..........
T 54. Number of
T� n• 46 ❑ Yes 47 D No bathrooms Partial........
I hereby certify that the proposed work is authorized by the owner of record ,
and 1 have been authorized by the owner to make this application as his
authorized agent.
SIGNATURE Of AGENT
ADDRESS
(NUMBER) (STREET) (CITY)
APPROVED BY TITLE
DATE 1q
DEPT. FILE COPY
Z
BUILDING
PERMIT
VALIDATION
DATE 1 PERMIT NO. 183
APPLICANT Arj1RESS '�
(NO.) (STREET) (CONT R'S LICENSE)
NUMBER OF
PERMIT TO ^y" (�l STORY DWELLING UNITS
(TYPE fdF IMPROVEMENT) N0, (PROPOSED USE)
/ ZONING j
AT (LOCATION) DISTRICT
(NO.) ( TREET)
0, BETWEEN AND
.0 (CROSS STREET) (CROSS STREET)
m
LOT
a SUBDIVISION LOT BLOCK SIZE
m
a
v
BUILDING IS TO BE FT, WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
Z TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
f
O
LL REMARKS:
AREA OR ESTIMATED COST �. FE L�f o u
VOLUME
(CUBIC/SQUARE FEET)
OWNER BULL
ADDRESS BY
(Affidavit on reverse side of application to be completed by authorized agent of owner)