3C RUSSELL DR - BUILDING INSPECTION � .._ CrL-T-0 LETNI
PUBLIC PROPERTY
DEPARTMENT
KI%MF]ti!Y DRISCOLL
MAYOR "�'/� ._e0l 120 WASHING ON Snt� "T# ' =,N.stncHLSLTTS 01970 r�/(�'7 TEL,978-745-959S•FAX 978-740-96"
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: �r c: f Building:
Property Address:.
property is located in a; Conservation Area YIN_ _Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: fir' fG u
Address:
Telephone: B 7 B
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:
Mail Permit to: 1 O `7
d
I `
What is the current use of the Building? d c
Material of Building? If dwelling,how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone 3 ` ��� ( ) 9 -7
Mechanic's Name ��+ sf, Gum
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ J Sd Permit 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 bull a above stated
specifications. Signed under penalty of perjury
Date /! r
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