11 CLIFTON AVE - BUILDING PERMIT APP (002) PUBLIC PROPERTY
DEPARTMENT �J/7
I:BMHU-Ey DRISCOLL
MAYOR 120 WASHINCTON S7RFFr•SALEK MA.SSACHLSLI-M 01970
TEi 978-745-9595 ♦FAx:97&740.9846
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: ( I C l 1Ito 01 4JQ
Sa( 1^^o -)D
Property is located in a; Conservation Area Y®ALct--Historic District YA u a
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: S /? 71� IGn
Address: Ij C-1 tp-mo Aue- - —
sa e rn/ m D
Telephone: (0/7
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: .37K rPe-
oo-F
/ 8 SQu41zaJ �SrrSTrn� 4-5,pf-Io. t"
A-2c�nr-h�c�l�uct:� r h � e.1j-f-(1
�-s Pb4-lfi.
Mail Permit to: l S La2l h - p
e M.
e., e 5
What is the current use of the Building? rvd2 t-
.3
Material of Building?�cc of RRh2 If dwelling, how many units?
Will the Building Conform to Law? ° Asbestos? tj °
Architect's Name
Address and Phone
Mechanic's Name �J t 9 6d f a ,!4 ov i
Address and Phone o`2 �7 �,o /-0 e— O�m Utg7o
Construction Supervisors License# HIC Registration# 160(0/7
Estimated Cost of Proj ct$ 6�QU 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 property 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-Q' U y\Onf1�
Date`3 act 0/0
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