120 WASHINGTON ST - BUILDING INSPECTION (3) CrMCIF SALE --
PUBLIC PROPERTY
DEPARTMENT
l
/J\RIERLEY DRI5COLL �
MAYOR 120 WASHINcmN S"rRFFC•SALIEW MASSACHLSLITS 01970
1F3-,978-70i959S 0 PAX 978-740-98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
ESITEATION y, Building::
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: G
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 (sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: A ;^ or— - -- Mail Permit to:
What is the current use of the Building?
Material of Building? X r4ac if dwelling, how many units?
Will the Building Conform to Law? ��`� S Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name p ✓, e�
Address and Phone 10
Construction Supervisors License# 0 qcs- 737 HIC Registration#
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
�Q2 �� `� An Additional $5.00 is added as an
e (_ ig11,�1(01 j�f�/�� 0//%✓� 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 b to the above stated
_�c__
specifications. Signed under penalty of perjury X— � A" L
Date
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