4B RUSSELL DR - BUILDING INSPECTION EITf-OFSAL 1 --
PUBLIC PROPERTY
z DEPARTNfE►NT
KI\WFAI.SY DRISCOLL
MAYOR n
�1WW11, .S'
AL K MASUQll:s6'IYs 01970
D y� 'ILL•978-74S-9S95*Fib[:978-740-98"
APPLICATION FOR THE REPAIR. RirNOVATION, CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
I A SITE INFORMATION
Location Name: Building:
Property Address
Property is located in a; Conservation Area Y/N Historic DlsMct Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: G1n
Address: C/,/-33
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use u New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
c_T/IS �G� /�-Z�l--� �n��xrsr_�(�G._. � G�iM✓'..ef V'2n�i� ,�5'�t'/Y1 ,
The Chimney,Guys l
P.O. Box 4074
- - -- - -- - P-eabedy,31A 1-960-- ---------------
Mail Permit to:
What is the current use of the Building? C,�� CIO -
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name The Chimney Guys
Boa 4074 t
Address and Phone
Mechanic's Name97A-977-9900
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$-,"-7 00, Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
- -..---- -- - -- -- --- _-- Estimated-CostX-$1-t/$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 o e above
/sttaaatteedd
specifications. Signed under penalty of perjury X
Date
of �
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