19 WISTERIA ST - BUILDING INSPECTION a
EnT-OFSALE, — --
PUBLIC PROPERTY
DEPARTZ"VIENT 44
KJAMM fiY ORMCUtl.
MAYOR 120 WAwNGTON STREET•Ste:,X&AACHMI-M 01970
1F1:978-74S-959S• FAr 97&740-98"
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: Building:
Property Address:
A W IS�e��. S-�
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: Kr +V 1rS . _ Oa✓�
Address: 1 c, W,4,?,;C, S- ` LAA k {i
Telephone: q'?6 4
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition ►VU 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 I New
Brief Description of Proposed Worts; w7ta,�—t�Q r✓� _
,C'
Mail Permit to:
f
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 T
Address and Phone C ✓-� � Dl 15
Construction Supervisors License# 06 )q75 HIC Registration#
Estimated Cost of Project$ O Permit Fee Calculation
Permit Fee$ Estimated Cost X$V$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 ttp above stated
specifications. Signed under penalty of perjury X //
Date 1
0
1 •� � N N
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