2C RUSSELL DR - BUILDING INSPECTION - C:IT�OF�XLEti _.. li
PUBLIC PROPERTY
DEPARTNL LENT
I:I.�NFFIIJiY D.e.-v
%Wva
130 WAUCMGWM h FW. r♦SAWk%t&% 3fLS6l'IS 01970
THL 9'. US-%9S 0 FAM 976-740ANL
APPLICATION FOR THE REPAIR. RENOVATI N CONSTRUCTIONS
DEyiOLITION, OR CAANGE OF USE OR OCCrrnANry, FOR ANY EXISTING
STRUCTURE OR BUILDIN[�
1.0 SITE INFORMATION "
Location Name: Building: o�
Property Address:-
Properly is bcated in a;Conservation Area Y/N Historic DWkkt Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Z
Address: a e-'L'��
Telephoto: 9 7a `) '7-7 Lam
3.0 COMPLETE THIS SECTION FOR WORK IN EYISZING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use y N
ow
Demolition Existing
FBdApproximats year of Area per floor (sf) Renovated
nstruction or renovationexisting building New
ef Description of Proposed Work:
- -P.O. 13oz 4074 -
Mail Permit 6. Peabody, MA 01960
What is the current use of the Building?Material of Building? It dwelling•how many units?_---
"It the Building Conform to Lem ney uys Asbestos?
ArchiteaSName
Address and Phone Peab^
Mechanics Name
978-977-9900
Address and Phone HIC RegWbsdw 0
C xmtvction Supervisors License 0
Estimated Cost of Proted Permit Fes Calculation
Permit Fee S c?�Dd Estimated Cost X$11$1000 Residential
-- - - Estimated Cost X S11/$1000 Comrmmercla! --- -
- An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property 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 pedury
Date -7
N
w
0 m �. • `\ , all
9 t QV y
a