12A RUSSELL DR - BUILDING INSPECTION (3) CITY-OF" ML
PUBLIC PROPERTY
DEPARTMENT �/ l
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TH-M7454S"•FAX M740-9646
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
OCCU
DEMOLITION. OR CHANGE OF USE OR PANCY FOR ANY EXISTING
STRUCTURE OR BUELDINC
1.0 SITE INFORMATION
Location Name: Building: a? r9
--
/a Gt- �Zw'a2.� CZL
Property is located in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
1.1 Owner of Land
Name:
Address:
Telephone: 7 - 9 7-7 -qI COMPLETE THIS SECTION FOR WORK IN 9S ING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
The Chimney Guys
P.O. Box 4074
_..
- -- --- 978=977=9900--- -- --- - - - ----
-- Mail Permit to: - - -
What is the current use of the Building?
Material of Building? If dwelling,how many units?�—
Will the Building Conform to Lawf
Asbestos?
Archittecre Name 4
Peabody,MA 01960 ( �
Address and Phoms' 978-9 -
Mechanies Name
Address and Phone
Constriction Supervisors License# HIC Registration#
Estimated Cost of Project 5 Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/111000 Residential
Estimated CostX$11/$1000 Camrmercial—
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
Date E-45-o-7
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