3D RUSSELL DR - BUILDING INSPECTION PUBLIC PROPERTY
DEPARTMENT
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MAYM 130WAvuN=w sn =•yutiK%(ASSAC111:StTiS OL970
1k1:MUS-9"S♦PAR;978-740.9W
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: 3
- -
3
Property Is located in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 3 . (0
Telephwe: '9 '7 7 c! Op
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition oNew
Renovation Number of Stories
Change in Use o2
Demolition
Approximate year of Area per floor (sf)
construction or renovation
of existing building
9def Description of Proposed Work:
The Chimney Guys
- -- Peabody,--? A0~ - -
---—- ---Mail Permit to: - - - -
What is the current use of the Building?
Material of Building? It dwelling,how many units?
Will the Building Conform to Les Gbireaay r_..yc Asbestos?
Architeds Name O. Box 4074
Address and Phone
Peabody,MA 019
Mechanic's Name
Address and Phone
Construction Supervisors Ucensse�it� HIC Registration#
Estimated Cost of Projed i1= Permit Fee CaleuMm
Permit Fee: Estimated Cost X$7/311000 Residential
Estimated CostX$11/51000 Commercial---------..-- -An Additional $5.00 is added as an
Adminisimtive 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 9 s C'�
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