21 COLUMBUS AVE - BUILDING PERMIT APP (002) ETTY--OF- r L
PUBLIC PROPERTY
DEPARTMENT
Kim5FA EY DRI5COLL
MAYot 120 WASHING TM SMEEr•&UXK MASSACHLShTiS 01970
TVL 978-74S-959S•FAX 978-740-9846
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: Z/
property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION a E�
2.1 Owner of Land _-�?
NName: CL..9d,0Ge lIC4/N e:SS
Address: pz/ �.0 L(�Kt9lXs �
UU �� 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
construction or renovation
of existing building New
Brief Description of Proposed Work: ��
Mail Permit to: p t t/ 13✓S � �^'�
What is the current use of the Building?
Material of Building? Otyt� If dwelling, how many units?
Will the Building Conform to Law? Asbestos? NU
Architect's Name
Address and Phone )
Mechanic's Name
Address and Phone
Construction Supervisors License# (>99sol HIC Registration# O
Estimated Cost of Project$Z&OP Permit Fee Calculation
Permit Fee$ 1/9-- `l* Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional$6.00 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
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