5 ROSLYN STREET CT - BUILDING INSPECTION 4 z
What is the current use of the Building? eu
Material of Building? if dwelling, how many units? 14-1
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone I
Mechanic's Name GJ
Address and Phone
Construction Supervisors License S HIC Registration#
Estimated Cost of Project s ADO 46 Permit Fee Cakxilalbn
Permit Fees Estimated Cost X$7/$1000 Residential
Estimated Cost X s1141000 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 . Gy )
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PUBLIC PROPERTY
DEPARTMEINT
K{\O1FA1.6Y DRACULL
Naval 130 WASwN=W SrRE=•"U0k MA%ACHLSL1IS 01970
Tot 978-745-959S 4 FAX 976-740.98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY,FOR ANY VaSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Nams: Building: a / ,ry,
Property Addre1s
✓�iC�/.lJ��/ U7" C a y
Properly is located in a; conservation Area YIN Historic Dfatrk:t YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: /y
J' 1('a r T L ov 7—
Telephone,
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
,Ile
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