164 BOSTON ST - BUILDING JACKET (-']-'I.'Y OFSALENf
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PFRrvirr
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELL
IMPORTANT:Applicants trust complete all items on this page
SITE INFORMATION
Location Name Building_
Property Address 2
Map If—
Located in: Conservation Area YN--_,dZ Historic district Y/N 11�
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential (hotel/motel RI
(check one) Assembly(churches) Al
New Building Assembly(nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration Business B
Repair/Replacement Educational E
Demolition Factory (moderate hazard) F1 —
Move/Relocate Factory (low hazard) F2—
Foundation Only_ High Hazard [I—
Accessory Building Institutional (residential care) 11 —
Other(describe) histitutional (incapacitated) 12—Institutional(restrained) 13
Mercantile M
Storage(moderate hazard) sl —
Storage(low hazard) S2
OVVNERSIIIP INFORMA1 ION(Please type or Print Clearly)
OWNER Name Cj-Z4,,1
Address_ Z 4 BoS Z11-17 S Z!� -.�,71j-�-er
Telephone
DESCRIPTION OF WORK'I 0 BE PER FORM E 1)
ESTIMATED CONSTR(;C FlOjN COST
1,
coNrRAc'roa INFORMATIONName le- A
Address /� rh, �f -cn-_
Telephone 97fs 7ys=83ij
Construction Supervisor's Lic # 7I
Home Improvement Contractor# /o (- FIT-�
ARCIII'I'ECT/ENGINEER INFORMATION
Name
Address _
Telephone
Mass. Registrat' #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed °a ,�71
Date
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