10D RUSSELL DR - BUILDING INSPECTION CITY-OF
PUBLIC PROPERTY
DEPARTMENT
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APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION,OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR WELDING
1.0 SITE INFORMATION
Location Name: Building p ^0
--- -- ---- -------
Fropody In located In a:Conservalion Area Y/N Hisizift Dlsbict YJN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
I
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition ®Rno
Renovation Ci Number of Stor
C/
Change in Use Demolition Approximate year of Area per floor (sconstruction or renovation
of existing building
a&J Description of Proposed Work:
-fin,e.,.e ale
The Chimney Guys
P.O. Box 4074
97ft_977_"00 -
--- ---Mail Permit to: --- - --
What is the current use of the Building?
Material of Building? if dwelling.tww many units?
Will the Building Conform to Law?-ph,ea;wney Asbestos?
Architect's Name 4074
Address and Phone 978-977-9900-
Peabody, MA 01960
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration N
Estimated Cost of Project i o200� Permit FeP Cakwlation
Permit Fee: Estimated Cost X$7/$1000 Residential
Estimated Cost X$1 V$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
Date
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