001B FILLMORE RD - BPA B-2007-729 EI`I'Y-OFSALEN —
PUBLIC PROPERTY
DEPARTMENT
MAroa 120 WASHINGrON 9AEFr 4 SAi MANSACHt;SLM 01970
lam 978-74S-959S 41,FAx:978-740-9U6
3t� �. -F. . Y ,
APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: _ Q �d SA/PA,<
properly is located in a;Conservation Area Y/N Historic District Y/N_Az--
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: �9rJ
Address:
,r" B Y/ %Jrnc�iaL
Telephone: 9 -79y- /.2e3
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 New
of existing building
Grief Description of Proposed Work: ,gyp
The Chimney Gays
01960-_--
--
978-977-9900
—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?Th. y Guys- Asbestos?
Architect's Name P nl Rox 4074
Address and Phone Peabody,MA 01960
978-977-9900 Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost f Project$ 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 the above stated
specifications. Signed under penalty of perjury X
Date
V
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