1 BEACHMONT RD - BPA-2007-686 INSTALL PELLET STOVE EI'�OF-SAI;E
' PUBLIC PROPERTY
DEPARTMENT
KI%IBFI.EY DRISCOLL
MAYOR i?0 WASHINGTON STREET•\AL Fu .MA.SSACHLSL11S 01970
11rt 978-745-9595 0 FAX:979-740-9M
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 Ad ss: Ul�I
E�c��
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �� d
Name:
Address:
Telephone: 1i 7 7Y 7
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
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building? ��� f���/�L� ✓ -
Material of Building? If dwelling. how many units
Will the Building Conform to Law? t/ i°S Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Pro ect�� �� 7 SO.U 0 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 stat
specifications. Signed under penalty of perjury X
Date °� O
of
N
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