4A RUSSELL DR - BUILDING INSPECTION EITY-OFS-ALE ----
_ PUBLIC PROPERTY
�✓ DEPARTMENT
KISMERIEY DRISCOLL rtD i P)P.-W r:. IC ?
MAYOR 120 WASNING",S`IREEf,,JAIk ,,�tAAACHLSLI-M 01970
Ifi 978 7i5 9595 FAY 97&740-9846
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APPLICATION FOR THE REPAIR, R9NOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1 A SITE INFORMATION
Location Name: Building: _ !r o�v�
Property Address:
Property is located in a: Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.4 Owner of Land
Name: e e
Address:
Telephone. 9 7a-
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation v Number of Stories Renovated
Change in Use CQ New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
grief Description of Proposed Work:
The Chimney Gu
P.O. Boa 4074
Peabody,-MA 01960
Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
The C111mucy Guys
Architect's Name v n Box 4074
Address and Phone Peabody,MA 01960 ( )
Mechanic's Name 978-977-9"0
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$-/ 2Q Permit Fee Calculation
Permit Fee$ 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 build to the above stated
specifications. Signed under penalty of perjury X
Date
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