12-A RUSSELL DR - BUILDING INSPECTION CITY-OF Em
-
�I� J PUBLIC PROPERTY
DEPARTMENT
AIM SEILLEY DRISCOU.
MAYOR qW 676 ,4 120 WASHINGTON STMEr�(% SAltai,.tisncxt:Stl'rs 01970
-ML,978-745-9595 • FAx:978-740.9W
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: /2 - A jZ s s L f / D r ,
Property is located in a: Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: cI-� S _ 7 41 _ 1 S 110
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing Z
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing SL SY-
Approximate year of Area per floor (SO Renovated S to f=
construction or renovation SG
of existing building New
Brief Description of Proposed Work:
Mail Permit to: / /2 4 12uss�li Drriye,
What is the current use of the Building? �> .I
Material of Building? �d"� ^- If dwelling, how many units?
Will the Building Conform to Law? Yes Asbestos? f"
Architect's Name N Z
N
Address and Phone N/A ( j
Mechanic's Name
Address and Phone
Construction Supervisors License# n 1?3 )K 6, HIC Registration=7
Estimated Cost of Project$ 1, 0092 Permit Fee Calculation
Permit Fee$ `T"S'a Estimated Cost X$7/$1000 Residential
a� Estimated Cost X$11/$1coo 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 2,0 -0 G
of -�
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