85 DERBY ST - BUILDING PERMIT APP JACKET EI'I�OF
PUBLIC PROPERTY
DEPARTbIENT
&MkK.VAStAU1lSt1lS 01970
,APPCICA` V-0- FOR THE REPAIR RENOVATION, CONSTRUCTION
DEMOLITION -OR CHANGE OF USE OR OCCOPANCYEXISTING-------------- FOR ANY
STRUCTURE OR BUILDIN .
1.0 SITE INFORMATION
Location Name: Building: t
Property Addresw—.-
- -- - -
Property Is located In a;Conservation Ares Y/N �4 Historic District Y(,F7
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land C ( o ✓l
Name:
Address:
Telephone: Q1 1 $4 - D 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 (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: 1
in
Mail Permit to: 3
What is the current use of the Building? \�
Material of Building? Ws'X"— '0 O if dwelling.how many units?
Win Me Building Conform to Law? Asbestos?
`
Architect's Name �v � V, L tt n
Address and Phone (
Mechanids Name i w �
Address and Phone 1 R L
Construction Supervisors License# S 61 U HIC Registration#
Estimated Cost of l�j, i t PermN Fse Caleulatlon
Permit Fes Estimated Cost X$71$1000 Residential
Estimated Cost X341/i1000CanmerciaL------_.-- - .. .. ..
An Additional $5.00 is added as an
Administrable 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 pelury
Date
{ o�
z
� � a
a