3B FILLMORE RD - BUILDING JACKET EITrOF
I PUBLIC PROPERTY
DEPARTMENT
�(wY'ol 130 W.WUNGWO b"M='*&"74 M&%ACHLShM 01970
Tm-974743-9S"•FAX 97M740.9W
APPLICATION FOR TAR REPAIR RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR WELDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:-�y_p fl,»��r -- - ----- - - - ----- -
Property In bested in a:Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: f
Address:
Telephone: 55) + r I?k77 —9.0
3.0 COMPLETE THIS SECTION FOR WORK IN EVIATING BUILDINGS ONLY
Addition Existing
Renovation �C 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:
The Chimney Guys
—- —- - Peabody,MA 01960- - -
-- Mail Permit to: - - --
What is the current use of the Building?
Material of Building? If dwelling.how many un'ds?
WIN the Building Conform to Law Asbestos? -
Architeas Name
Peabody,
Address and Phone MA 01960 ( j
978-977-4900
Mechanic's Name
Address and Phone
Construction Supervisors License 0 HIC Registration 0
Estimated Cost of Projed i ad. Permit Fee C"hition
Permit Fee i Estimated Cost X$7/$1000 Residential
Estimated Cod X$11/S1000C -- - —An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building
�P[ermit to bui the above stated
specifications. Signed under penalty of Perjury /-
Date2 5 6 .17
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