5C DEWEY DR - BUILDING INSPECTION JACKET PUBLIC PROPERTY
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I'm 978-745-959S FAX 978.74e-9646
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTLNG
STRUCTURE OR BUILDING
!so SITE INFORMATION
Location Name: &- Building:
Property Address: S_C L
property is located in a; conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: P, t
Address:
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 (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
><e//ice Gems. a x /fie, c_v s9 �Z
C r$c- Gov�r Cc�J «, n C
—zJ-
- -- Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Coat of Project$mod' c5Permit Fee Calculation
Permit Fee$ Z�✓ Estimated Cost X$7/$1000 Residential
GAZL—
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 ove stated
'///'
specifications. Signed under penalty of perjury X
Date o
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