63 PALMER ST - BUILDING INSPECTION (5) EI`I`V-OFL
' PUBLIC PROPERTY
DEPARTMENT
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To;978-745-9S9S#FAX 979-740-9646
APPLICATION FOR THE REPAIR- RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
property is located in a;Conservation Area Y/N Ak9 Historic District Y/N A"
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: Gtl�� Y
Address: Pp 38YlX�SS
Telephone: 1 j 3
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing A
Renovation Number of Stories Renovated
Change in Use Z( New
Demolition _ Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building � " 9 New
Brief Description of Proposed Work:
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--- Mail Permit to: 42 Se-6LAI
What is the current use of the Building? La PA
Material of Building?`, 9k,r,d-�tt� ) If dwelling. how many units?
Will the Building Conform to Law? )Z4:�:s Asbestos? AP-
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone 4 9�2s,1/l �� /riR l.�ha CAI � � ���� �5✓�J�
Construction Supervisors License# 0-1?�K5-6 HIC Registration# /3/,31 .R�Q
Estimated Cos f PP GO .`s Permit Fee Calculation
Permit Fee$ / Estimated Coat X$7/$1000 Residential
Estimated Cost X$11/$1000 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 X
Date 1,2 z/�
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