17 VISTA AVE - BUILDING INSPECTION ' PUBLIC PROPERTY
DEPARTMENT
KI\44ERI.EY DRISCOL L / ,L
MAYOR 11-0 WASHINGrON$IREEr• SALEK MASSACHUSE1-M 01970
TEL,978-745-9595 ♦ FAx:97&740-9846
APPLICATION FOR THE REPAIR; RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION "nn
Location Name: 111 S E , Building:
Property Address:
Property is located in a: Conservation Area Y/N ALO Historic District Y/N L u
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land STC- tra T lv
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: '
Mail Permit to:
What is the current use of the Building?
Material of Building? -A� If dwelling, how many units?
Will the Building Conform to Law? f a eo Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name 'u1 /
Address and Phone
Construction Supervisors License# r�)a 0 e6e HIC Registration# /oo
Estimated Cost of Project$ /0 0 00, 010 Permit Fee Calculation
Permit Fee $ 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
Date � G
of
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