0000 PICKMAN PARK CLUBHOUSE - BLDG PERMIT EITY-BFSXLEm -
PUBLIC PROPERTY
DEPARTNI&NT �/-o 7
AI\R1FA-EY DRISCALL ➢tfi„ L ! .[ e
MAYOR 1721 WASHINCT➢➢N Siukry S,uBei,NASSAo➢t:SLXIS 01970
T.EL,'978-74S-9S95 9 FAX 97&740-96"
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: i f� Building:
Property Address:
property is located in a;Conservation Area YIN r� Historic District Y/N/_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: _ Qi✓i saco o�
Address:
LT=eiepne.
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 I New
of existing building
Brief Description of Proposed Work:..T�n./�^�uG�
The Chhnney Guys
-- -- --— --- ---Peabody,MA-01960— ---
Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling. how many units?
Will the Building Conform to Lawilm_iehfmucy y_ Asbestos?
Architect's Name P n Rnx 41574
Address and Phone Peabody,MA 01960
978-977-9900
Mechanic's Name
Address and Phone
Construction Supervisors License#�_HIC Registration#
Estimated Cost of Project$ 96,04 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 a above stated
specifications. Signed under penalty of perjury X
Date
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