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NT
PA
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORI•AN'r: Applicants must complete all items ou this ra'e
SITE INFORMATION
Location Name ,5&6W !'l/l't ff A/Sotl'Rsuilding
Property Address N is ff f 4--�N 5Q-
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3 RJ
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building_ Assembly(restaurants Se clubs) A2r_A2ne_
Addition Assembly(churches) AI
Aherution / Business B_
Repaid Replacement Educational E_
Demolition Factory(moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard 11_
Accessory Building Institutional (residential care) Il
Institutional (incapacitated) 12_—
Institutional (restrained) 13
Mercantile NI _
Storage Sl Moderate Hazard
Storage S2_Low I Lazard
OWNERSHIP INFORMATION(I'lea.se t_v or Print Clearly)
OWNER Name
Address 461 57Q
Telephone
Signature
DESCRIPTION OF%WRR TO BE PERFORMED
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CON I RAC'I'UR INFORMA'FR)N
Name
Address �7_ L(ftk72YL S ? .Gly geLgw 4,14 d18d6
Telephone _4q /Q» Zr�33
Construction Supervisor's Lic # -4
Home Improvement Contractor# 4 :327ZI
:�RCIII'I'!?C'I'/h\t:INFISR INFORMATION
Name
Address
Telephone
Mass. Registration #
1'FRn1IT FEE CAI,CULA'r1ON
Estimated Cost x $111$1,000 + $5.00=
Ct)h1Nit:1N1`S
I
The tutrlersigtted applicant does hereby attest that all inforotatioit stated above is trite to the best of my knoivlertge
ruiner the penalties of perjury
l
Signed (owner) (avant)
APPROVED BY :
DATE APPROVED: Y�13/D9