30 BROAD ST - BPA-2007-20 KITCHEN � 1
` PUBLIC PROPERTY
,DEPARTMENT
KIMBERLEY DRISCOLL ,
MAYOR 120 WASHINGTON STREET♦SA LK ANSSAC3LLS6llS 01970
TEL.978-745-9595• FAX:978-740-9M
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 Address.
`. 30 GrOU�
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.4 Owner of Land
Name: < V.r, t�_ eve �enC'VCnTv
Address:
Telephone:
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 (sf) Renovated 2
construction or renovation New
of existing building
% Erief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building? e
Material of Building? 6� If dwelling, how many units?
Will the Building Conform to�J//A
naw? Asbestos?
Architect's Name J
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# 1�'-5 01S`�D`lLJ HIC Registration# S 6-5
Estimated Cost of Project$ CB 07 lo&() Permit Fee Calculation
Permit Fee$ Estimated Cost X $7/111000 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 t the ve stated
specifications. Signed under penalty of perjury
Date 7 iu d
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