6C RUSSELL DRIVE - BUILDING INSPECTION -CITY-OF SALEC
PUBLIC PROPERTY
DEPARTMENT
MAYOR 120 WASHINGTON SST Snt.rlr,MA1UCHl;561'I15 01970
1f19'&74S-959S 0 FAM 9W40.98"
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: T Building:
-
S
Property is located in a:Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: SGy h
Address:
Telephone: 7 3
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 (sO Renovated
construction or renovation
of existing building New
Bcief Description of Proposed Work:
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?
Architect's Name
Address and Phone
Mechanic's Name Tj+ C ti r" ' DNS
Address and Phone /� O ✓�`��— d7�
Construction Supervisors License# HIC Registration#
Estimated Cost of Project S 2,300. (50 Permit Fee Calculation
Permit Fee$ ZS' Estimated Cost X$71$1000 Residential
Estimated-Cost-X-$11/$1000 Commercial -------
An Additional $6.00 is addedas 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 above stated
specifications. Signed under penalty of perjury X
Date /� �s�
0
j� O U y ~
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