4C RUSSELL DR - BUILDING INSPECTION DEPARTMENT
KINMERLEY DRISCOLL
MAYOR 120 WASHIN(TON SIREEr
SALLM.MASSACHl:561'IS 01970
TEL-978-755-9595 0 FAx:978-740-9U6
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: Pic Fp2V- CoaAs Building:
Property Address:
NC 24,155'e11 D2
Property Is located in a; Conservation Area Y/N Historic District Y/N_t
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: e66�C /e___s o ✓
Address:
yG 2«,sst-l/ D2
Telephone: 07`1?-
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 (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Repot e 't YI sTt' ✓cJ F'i'rae O /ACe i4Nm4t
Mail Permit to: 7/e C/,;,I,Ae� 6, s ,o 0 6c-s<
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law?
Asbestos?
Architect's Name
Address and Phone
Mechanic's Name Xe �� cO
Address and Phone Qo 602'
Construction Supervisors License# HIC Registration#
Estimated Cost o r 62`" Permit Fee Calculation
Permit Fee Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $6.00 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 X4--,
Date i _3 06
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