63 PALMER ST - BUILDING INSPECTION (6) EI�'Y-OF�XC
PU'Q
BLIC PROPERTY
DEPr1RTbiENT
WAYOI 120 WASHING ON h-MEEr 0&M.EK MANSAcxLUMS 01970
��^-I� 1Vi:979-745-9595*FAX 97&740.95"
ev
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 AI& Historic District Y/N A)
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
[Telephone:
ame:
ddress: ISO -Ox 38'�,6,5—
G� b> i� >
�- �`J- ? - .3
3.0 COMPLETE THIS SECTION FOR WORK IN E)LST"Nr BUILDINGS ONLY
Addition Existing n
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation f� g
of existing building New
Brief Description of Proposed Work:
cv�//l��l �//~�wei� t�1�J
96 I6 /�/7Cy t 41 ]— S-f, f I INELt1 �� s��rUOV1p f E
1�5`f'����� �} �/�[•t/ EXEC, NE7•t1 (��v}vt yilrY�t -r-�Gq f
Mail Permit to: 4 9
What is the current use of the Building? z,IAP,4 41
Material of Building?�Z N,4 44174 If dwelling. how many units?�4
Will the Building Conform to Law? Asbestos? A/
e
Architect's Name
Address and Phone
Mechanic's Name ?(
Address and Phone H{4 � ��al/� g
Construction Supervisors License# 66 HIC Registration#/-31,2 22
Estimated Cost of Pro'ect t Permit Fee Calculation
Permit Fee$ WI Estimated Cost 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 s
specifications. Signed under penalty of perjury
Date
I
0
a
a a
F= Cal (> >