2B RUSSELL - BUILDING INSPECTION PUBLIC PROPERTY �\
AI% DEPARTMENT
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RIERI.EY R DISI:OLL _ �/
MAYOR ) lA WASHING oN STxEEr•SALyK\AssAcH sLi-M 01970
TEL-978-745-9595*FAX:978-740-9946 lb
APPLICATIO 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_jaL Historic District Y/N _4�
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: e/JF24e),eS 0,eif2�e
Address:
Telephone: 33g a03 'bl '17
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:
/�emove co� ple��
Z�Stfl 1( N p U> L&-A I JIn
Mail Permit to: Po Sou yo7y f�c��d�slA �✓c�`j
What is the current use of the Building? L Gzr C�C�
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ Perk Fee Calculation
Permit Fee$ 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 stated
specifications. Signed under penalty of perjury X
Date
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