12C-066 (6) ZONING •
FRONT DISTRICT
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SIDE / SIDE YARD
REAR YARD
IX. SITE OR PLOT
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NOTES and Data — (For department use)
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IV. IDENTIFICATION — To be completed by all applicants
Name Mailing address — Number, strrc°t, citN, and tats' ZIP code Tel. No.
Owner or
Lessee f
2.
l l / i e �iders
yf ( �� c License No.
Contractor r
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 111a Application date
00 NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD — For office use
Plans Review Required Check Plan Review Date Plans B Date Plans
Fee Started y Approved By Notes
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Date Date
Permit or Approval Check Obta ned 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
Permit number
Building
Permit issued ' r 19'7 7
Building
Permit Fee
Certificate of Occupancy S
Approved by:
Drain Tile S
Plan Review Fee
TITLE
x ai
o °} (rite of Nart4alnrttan
� � �IrlssticlTutsctts
�b
Office of the �nsptrtor of anilbings
APPLICATION FOR
Page ;l�� Plot l� tj l?A, ZONING PERMIT AND
9 r I BUILDING PERMIT
IMPORTANT — Applicant to complete all items in sections: 1, 11, 111, IV, and IX. Z
O
�'/1 /�j l ZONING
I• AT (LOCATION) rL / nt-I t��%L � DISTRICT L,'1?
LOCATION
(NO.) (STREE
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
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— 20 I
— — — ndustrial
3 � Alteration (See 2 above) ❑ ,
14 Transient hotel, motel, 21 Parkin are e
4 Repair, replacement or dormitory — Enter number ❑ 9 g g
5 Wrecking (If multifamily residential, of units ——————— — � 22 ❑ Service station, repair garage V
enter number of units in building in 15 Garage 23 Hospital, institutional
Part D, 13)
6 Moving (relocation)
16 Carport 24❑ Office, bank, professional V17❑ `
❑ 17 Other — Specify 25 ❑ Public utility
7 Foundation only _ 26 ❑ School, library, other educational 1
B. OWNERSHIPr LO Li 27 ❑ Stores, mercantile
8 Private (individual, corporation, ` n
r 28 Tanks, towers
nonprofit institution, etc.) rA/Z 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
y � y, processing plant, machine shop, laundry building at hospital, elementary
10. Cost of trnpre�rernent,,,,,,,,,,,,,,,, T r 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.)............. 1
11. TOTAL COST OF IMPROVEMENT $
III. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L; •D
for wrecking, complete only Part J, for all others skip to IV. y
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS M
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,
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
F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL 51. Enclosed ....................... 0
O
35 ❑ Gas Will there be central air 52. Outdoors........................
360 Oil conditioning?
L. RESIDENTIAL BUILDINGS ONLY
37 ❑ Electricity 44 ❑ Yes 45 ❑ No 53. Number of bedrooms..............
38 0 Coal
390 Other — Specify Will there be an elevator? Full..........
54. Number of
46 0 Yes 47E:] No bathrooms Partial........
INSPECTION RECORD
DATE NOTE PROGRESS - CRITICISMS AND REMARKS INSPECTOR
FIELD COPY
BUILDING
PERMIT
DATE March 18. 192_ PERMIT NO.��-
APPLICANT 9.Yk7 AV = ADDRESS
(N0.) (STREET (CONTR'S LICENSE)
NUMBER OF
PERMIT TO T1A�$1�ffiE1 (_) STORY DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
ZONING
AT (LOCATION) 21 H&Told DISTRICT U(-
(NO.) (STREET)
rn BETWEEN AND
�o (CROSS STREET) (CROSS STREET)
a
LOT
n SUBDIVISION LOT BLOCK SIZE
m
O BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
O
m
O
Z TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
� (TYPE)
K
LL REMARKS: DMOUTTON
40U OO FEEMIT
AREA OR ESTIMATED COST $ $ 10 no
VOLUME
(CUBIC/SQUARE FEET)
J /
OWNER Stanley Em Cy= BUI t
ADDRESS 'O'er m BY