104 DERBY ST - BUILDING PERMIT APP JACKET EI`I S� OF'�-I'LE1C2
PUBLIC PROPERTY
DEPART'hIENT
KWHERLEY MSCOLL \
MAYOR
e7 1?0 W,�cHt -ON 978-744S-995595� 97S—i0- LW 01970
Fi \
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION v
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
/o L/
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION I
2.1 Owner of Land W I ��I t/!wl Kol 7f�lSl�l �f
Name:
Address:
_ [OLt bE26lt- Si S ('K .Ma- 01C170
Telephone: M f-/ 7 p
3.0 COMPLETE THIS SECTION FOR WORK IN FXIATINIP BUILDINGS ONLY
Addition *Existing
Renovation Number of Stori
Change in Use
Demolition
Approximate year of Area per floor (sf) ENew
ovated
construction or renovation
of existing building
Brief Description of Proposed Work:
RGSttl"jCF t`wr tz cE� 3 -TW[s
Mail Permit to:
What is the current use of the Building?
Res l i)e,)Tta-1--
Material of Building? If dwelling, how many units?
7
Will the Building Conform to Law? ye-5 Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ a aQ Permit Fee Calculation
Permit Fee$ 21P " 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 to the above stated
9 4
specifications. Signed under penalty of perjury X 11✓�""°""^
Date I! 1 0
1
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'O O Y
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