001A FILLMORE DRIVE- BPA-17-730 EI`i"Y-OFiLE� --
PUBLIC PROPERTY
�c�d dJ DEPARTMEINIT
KPLLffitl-EY DMSCULL -
MAYOR 12D WASMNMT 4 SAEEr 0 Sir,MAAACM:SLTR 01970
M 978-745.9495 4;FAE 978.740.9846
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
F1.051TEINFORMATnION
e: �G/-/t Building:
ess: �;//, a c cxvy-,
propertysocated in a;Conservation Area Y/N PJ Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: Ciz
Address: /—,�f IC//� on �✓r-•
Telephone: 97d9- 7YI - 1 al
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation /)o Numberr of Stories Renovated
Change in Use `r New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation New
of existing building
grief Description of Proposed Work:
M��
A r m Uc C�p�k- j c h.. ,I-/ 0--. i 9
T S / n,4,_/ Ge,,,i ch/MA.y Sys c�r2ec/ �✓
The Chimney Guy
-- --------- - - -- ----------- — ----- Peahody, A D1960 ------
8-977-9900
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 P.O. Box 4074
Address and Phone Peabody,MA 01960
979-777-7900
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost Project$ C?(:>` v o Permit Fee Calculation
Permit Fee$ 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 a above stated
specifications. Signed under penalty of perjury
P 9
Date
vl IN
� o
y� N
a
Ok,
F e C7 aV
.. o