4 BERTINI LN - BPA-2007-629 PELLET STOVE r CITY-OP J11L -
PUBLIC PROPERTY
DEPARTMENT
MAYOR 120 WASNINGCDN S MEEr "LEK M.thSAfifl:5tl'IS 01970
T41.978-745-959S*FAX 97S.740.98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
1A SITE INFORMATION
Location Name: Building:
-- Property-Address.-
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: p i -Z
Address: C� Qjty- C Atr� �45tV� MA .O(��p
Telephone: _
3.0 COMPLETE THIS SECTION FOR WORK IN EXIS UG 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: ��5•� � ���� ���
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Mail Permit to: -l-i 'Aakl�
4
What is the current use of the Building?
If dwelling, how many units? �
Material of Building?
U
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cos of Pr, O Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated-Cost-)F$11/$1000Commercial ---------
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 X
Date / 1-44027
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