2D RUSSELL DR - BUILDING INSPECTION (2) r. PUBLIC PROPERTY
DEPAR`?vMNT
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Slavoa 120 WASH1 .-mN S1xFET 4 SUM%X%%Am som 01970
'n-197&7i5-9595 0 FAX W&740-9M
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: gi, je , Agek , Building-
Property Address:
� -/D Rw55e/l 4Dl2
Property is located in w. Conservation Area YM A/ HWodc District Y/N=A-)
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: ,A OU E &cX
Address:
........-...
Telephone:
3,0 COMPLETE THIS SECTIONL FOR WORK IN EXIaTIN�= BUILDINGS ONLY
Addition Existing
Renovation �� Number of Stories Renovated
Change in Use 7 New
Demolition Existing -
Approximate year of Area per floor(sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
l�emot,e o/� pPewg ReplA.ce
t� 5bs�eA%� , �,vsr)q/1 .ve�cJ
1 d !Y JPY
�P e 2 i o►2 �; Q e P%"rls-C '�5 �s ''T�,�%L�� '" -
Mall Permit to: PeA7iody,NYA 0196d_
What is the current use of the Building? (
Material of Building? If dwelling,how many units?
Will the Building Conform to Law??' Asbestos? _
e htmrtey Guys
Architect's Name
Address and Phone Xwiibody,td A nt o6n ( )
Mechanids Name-- 978-977-9900__
Address and Phone --
Construction Supervisors License'# - HIC Registration#
Estimated Cost of Project'$ -,20CxZl� Permit Fee Calculation
Permit Fee$ ar-1_ O Estimated Cost X$71$1.000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional$&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 -
of
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