137 DERBY ST - BUILDING JACKET C-n-Y-_Or'SAL --
PUBLIC PROPERTY
DEPARTIMENT
ICI%IBFI .EY DRISCOLL
MAYOR
120 WtisHlNcrr)N SIRFEr*$w'uu MA1SACJit;561-IS 01970
1Ft 978-745-9595 0 FAx:978-740-9W
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION,_ OR CHANGE OF USE OR OCCUPANM FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION µ
Location Name: Building:
Property Address: /-3-;7-
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: (�
Address:
Telephone: L
3.0 COMPLETE THIS SECTION FOR WORK IN EXW NG BUILDINGS ONLY
Addition Existing
Renovation ✓ Number of Stories Renovated
Change in Use New
Demolition ; Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: ��
Pig.
What is the current use of the Building?
Material of Building?�,) LDg — If dwelling, how many units? y
Will the Building Conform to Law? Asbestos?
Architect's Name /v14 .
Address and Phone
Mechanic's Name ��� '`� s 9✓ �4�
Address and Phone 3
Construction Supervisors License#
Oro 7j�' HIC Registration#
Estimated Cost gf P ojecct$ Permit Fee Calculation
Fee$
Estimated Cost X$71$1000 Residential
Permit
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 bove stated
specifications. Signed under penalty of perjury
Date .7 Zs dG
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144
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