12D RUSSELL DR - BUILDING INSPECTION (2) What is the current use of the Building?
Material of Building? If dwelling. how many units?
wig the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name- n` c""4 U
Address and Phone �{v7y ,,/ /'te ol$wC D T -977 QQ O
Construction Supervisors License S HIC Registration#
Estimated Cost of Projed tZ2,73� zO Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/51000 Residential
Estimated Cost X$11/51000 Cornmerciat
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 bu the above sta
specifications. Signed under penalty of perjury
Date Z e7
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PUBLIC PROPERTY
DEPARTMENT
KuaEUEn oMCIAL
.MAVM 120 WASMN -rrw sn1E=.may.N/ASUCHI:Sh1lS 01970
I'M 978-7454S"•FAM 976-740-98"
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 YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: ¢ 7 OU
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 (sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: