6B RUSSELL DR - BUILDING INSPECTION EI`I -OFSALEN --
• PUBLIC PROPERTY
DEPARTMENT
Ki%rjFXLEY ONS:OLL
MAYOR 120 WASMN= a h-MEEi 'kM!-1 ;NAAAcHtsLj-m 01970
'147]08-74S-959S*FAX:979-740-9846
0 i
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
FPro-
SITE INFORMATION �A.,) eA e L
ation Name:. Building: - (�
perty Address:
S - r3 Rc sell (JrL
roperty is located in a:Conservatbn Area Y/N Historic District YIN A2_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: O Fl .J H A / 5
Address: R L,65 e) D IZ
- 13
Telephone: 9 7 ( O
3.0 COMPLETE THIS SECTION FOR WORK IN FYisTiNG BUILDINGS ONLY
Addition Existing
Renovation C/ Number of stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation New
of existing building
Brief Description of Proposed Work:
o/d l�� �i i� p/ice 5� �Te.,-� � sy✓ �.�// .ue
�5'G�.•-�o ue �w R
5CeeCc 42 Sy5rc��n � �ev� .45� coVeA?
The Chimney Guys
P.O. Box 4074
--- --------- -------Peabody,MAr01960-- --
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`fhe Chimney_Cryc Asbestos?
Architect's Name P.O. Box 4074
Address and Phone Peabody,MA
UPPOU
9/9-9/1-9900
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$1 SG>] Permit Fee Calculation
Permit Fee$(aI6-� 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
i
w
�1
L Cui