ZON ING AT (LOCATION) DISTRICT (STREET) LOT SUBDIVISION LOT BLOCK SIZE

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3 IMPORTANT - Applicant to complete all items in sections: I, II, III, IV, and IX. I. (NO.) (STREET) LOCATION OF BETWEEN AND BUILDING (CROSS STREET) (CROSS STREET) LOT SUBDIVISION LOT BLOCK SIZE APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ZON ING AT (LOCATION) DISTRICT :::; C II. TYPE AND COST OF BUILDING - All applicants complete Parts A - 0 A. TYPE OF IMPROVEMENT D. PROPOSED USE - For uwrecking" most recent use ;:! n n 1 0 New building Residential Nonresidential 2 0 Addition (1f residential, enter number 120 One family 18 0 Amusement, recreational of new housing units added, if any, in Part D, 13) 130 Two or more fami Iy - Enter 190 Church, other religious number of units ~ 20 D Industrial 30 Alteration (See 2 above) 140 Transient hotel, motel, 21 0 Parking garage 40 Repair, replacement or dormitory - Enter number 22 D Service station, repair garage 50 Wrecking (If multifamily residential, of units ~ enter number of units in building in 150 Garage 230 Hospital, institutional Part D, 13) 160 Carport 240 Office, bank, professional 60 Moving (relocation) 170 Other - Specify 250 Public utility 70 Foundati on only 260 School, library, other educational B. OWNERSHIP 27 0 Stores, mercanti Ie D Tanks, towers Private {individuo I, corporati on, nonprofit institution, etc.} 290 Other - Specify 9 0 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 bui Iding at hospital, elementary 10. Cost of improvement $ school, secondary school, college, parochial school, parking garage for, deportment store, rental office bui Iding, office bui Iding 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.) 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 48. Number of stories Masonry (wall bearing) 400 Public or private company 49. Total square feet of floor area, 31 0 Wood frame 41 0 Private (septic tonk, etc.) all floors, based on exterior 320 Structural steel dimensions Reinforced concrete H. TYPE OF WATER SUPPLY 34 D Other - Specify 420 Publ ic or private company F. PRINCIPAL TYPE OF HEATING FUEL 50. Total land area, sq. ft Private (well, cistern) K. NUMBER OF OFF-STREET PARKING SPACES I. TYPE OF MECHANICAL 51. Enc losed Gas WiII there be central air 52. Outdoors Oil conditioning? L. RESIDENTIAL BUILDINGS ONLY 37 D Electricity 440 Yes 450 No 53. Number of bedrooms D Coal 390 Other - Specify WiII there be on elevator? 54. Number of 460 Yes 470 No bathrooms { Full..... Partial......

4 NOTES and Data - (For department use)

5 IV. IDENTIFICATION - To be completed by all applicants Name Mai ling address - Number, street, city, and State ZI P code Tel. No. 1. Owner Lessee or Bui Ider' 5 2. License No. Contractor 3. Architect Engineer or 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 Addres s Application date DO NOT WRIT E BELOW T HIS LI N E V. PLAN REVIEW RECORD - For office use Pions Review Required Check Plan Review Date Plans Date Plans By Fee Started Approved BUILDING $ PLUMBING $ MECHANICAL $ ELECTRICAL $ OTHER $ By Notes VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS Perm it or A pprova I Check Date Obta ined Number By Permit or Approval Check Date Obta ined 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 Bui Iding FOR DEPARTMENT USE ONLY Permit number Bui Iding Use Group Permit issued Fire Grading Building Permit Fee $ Live Loading Certificate of Occupancy $ Occupancy Load Drain Tile $ Plan Review Fee $ Approved by: TITLE

6 VIII. ZONING PLAN EXAMINERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES IX. SITE OR PLOT PLAN - For Applicant Use BOCA FORM APEBP CIHb9 BUILDING OFFICIALS & CODE ADMINISTRATORS INTERNATIONAL, INC.