HomeMy WebLinkAboutMiscellaneous - Exception (345)SECTION 4 - W GRI=S COMPENSATION (bf.QL C 152 § 2500
Waiaas Cobspaasatiow lasurance effidavit must be
and submitted with this application. Failure to pmvide this d5davet win rmuh
in the daoial of tha iss�enoc ad'the btu - . ---- --• - - - _ _ _- _ _ ._
d5da*Attaobod`,Yes. . No....... 0
SKMON 5 Weri •f work a s4
New Cmistruebon - I;K
Existing Building 0
Repau(s) 0
Alterations(s) 0
A"tio n 0
Ammony Bks. 0
Demolition ❑
Other 0 Specify
Brief De=iption of Proposed Work
CC)N ' b c � sop6 al A -)e l c ti c `P
SECTION b - ESTIMATED CONSTRUCTION COSTS •
item Estimated Cost (Dollar) to be 'TEM.
Co etod licant
_
Whia
Mul er
1. Building
)Do, ozc
2 Electrical ,
- � S 060
(b) Es� Total Cost of
Cot�ttrctiolt
�L
/ Q� ��
3 Plumbing,
BW1ding Pqm1t fee (.) x -(b)
-
D 6
4 MecWmical AC
5 Fire Piotect9ap" 0 G
6 Total 1+2+3 5 to 060
CheckNumber
SECTION 7a OWNER AUTHORIUTION TO BB COMPLETED WEIEiV
OWNIRS AGENT OR CONTRACTOR APPLIES FOR RunnNG Fx iMIT
L as Owner/Authorized Agent of subject property
Hmby, autiiarite to act on
My behalf~ in all matters relative to work authorized by ibis building permit appheation.
S• lure. of Owner Date
SECTION 7b OWNEWAUTSORIZED AGENT DECLARATION
.as Owner/Authorized Agent of subject
P+pP�Y
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief '
0104J1�2o ec a -a rieA
Print Name
Si true f (timer/ t Date
M10' STQRII~S t SM .. a7 . �,. jr
BASEMENT'OR SLAB w
SIZE.OF FLOOR .TIMBERS I l 2 3 x ,v
SPAN / 'Mae
DIMENSIONS OFSRI$ x --
PAMENSIONS:OFPOSTS co -,-c. , -cl L4L1
DIMENSIONS OF GIRDERS y I VL U�
HEIGIIT OF .FOUNDATION — q °' TMCKNESS /p "
SIZE OF FOOTING to " X do r
WHEA % CHIMNEY 44-e ,k2,/
IS BUILDING ON SOLID OR FILLED LAND4-
IS BUILDING CONNECTED TO NA'T'URAL GAS LINE , e