203 ESSEX ST - BUILDING INSPECTION (2) CX
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APPLICATION FOR PLAN EXAMINATION AND III)I LDIN PLRNIYF ALL STRUCTURES EXCEPT AND 2 FAMILY DWELLINGS
IMPORTANT:Applicani-S must complete all items on this page
SITE INFORMATION
Location Name Building_
Property Address- Za? tS361- 521M-r
Map
To catediir. �ConseNation Area Y )J�LHistoric district Yi Use Groups
(check one)
Residential (3 or more Units) R—I—
Type of improvement Residential(hotel/motel RI —
(check one) Assembly (churches) Al —
New Building Assembly(nightclubs etc) A2—
Addition Assembly(restaurants, recreation) A3—
Alteration Business B
Repair/Repla neniv Educational E
Demolition V Factory(moderate hazard) F1 —
i'vlove/Relocate Factory(low hazard) F2—
Foundation Only High Hazard 11—
Accessory Building Institutional (residential care) I I —
Other(describe) Institutional(incapacitated) 17—
Institutional(restrained) 13
Mercantile M
Storage(moderate hazard') Sl —
Storage(!oN% hizard) S2
OWNERSHIP CNI-ORMAHON(Please type or Print Clearly)
OWNER Name z d 4&1,e�z,
Address 940 6oW Abr& )2W
Telephone
DESCRI PITON OF WORK TO HE PERFORMED
FSTUNIA[-ED CONSTRUCTION COST
CONTRACTOR INFORMATION
Name ew*rm
Address 89 Xis-49" QUAD Al Gl gli/lL� v414 p/4S l
Telephone 97� 7�
Construction Supervisor's Lic # 01176-7
Home Improvement Contractor# /Z`l362
ARCHITECT/ENGINEER INFORMATION
Name /vrhje,, S v�1 �IIcV l�i�l
Address o S rl Of-W
Telephone 478- 7 - 7 7
Mass. Registration # 6�
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all inf mation state o e is true to the best
of my knowledge under the penalties o,Fperjur
Signed
Date /-14-D z
6 11/a5
. s