1C NIMITZ WAY - BUILDING INSPECTION EI`I'Y-BF�AL 1 —
PUBLIC PROPERTY
DEPARTMENT
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MAYOR 120 WASHINGrON SIREur• SALEK WASSACHM-1-IS 01970
lVi 978-745-9S95•FAx:978-740-9W r
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING��
STRUCTURE OR BUILDING
IA SITE INFORMATION
Location Name: 9FieKMA,9 Pig(ZK= Building: -C
Property Address:
/-d N/'M l Z wA
Property is located in a; Conservation Area YIN-,d2 Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 50.5� h ve
Address: 1 _ �� r y r✓/A�
Telephone: 6'03- 9/8 - 6309
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation X Number of Stories Renovated
Change in Use a New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
/`�el�oue Co.V,Io/ere 192e&,A_ 47't2.e plAce,
�NSTRII .Neu/ 6eAIAl0 X 5y57e .
LF
-- - Mail Permit to: P. o /joys Y07c! Pegk->d� /+.tA o, 60
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ /7DO Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$1141000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
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