5B FILLMORE RD - BPA B-07-589 EI`I Y--OFSAL
PUBLIC PROPERTY
DEPARTMENT
a�roExl.eYORIx:u� '1 �f
MAYOR M WASHINGCON S1REFr♦$ALk1M,,%L%ssACHLsLrm 01970
1-FL 978-745-9595*FAX 978-740-98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: S$ =%L L /`z pit r ` ?ea", Building:
Property Address: /
5,45 'Fi 111L2VT2G
Property is located in a: Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: EAT lea^-e-
Address:
Telephone: y7,9 - 7YS-110 tl
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 (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
�L/�LuCr.>uj T4'- 'h'44'wrr eAA5C =lvf7-lt N1R/Co-
Ge/`�'G7� G(dtiATdt!C �T Leltisx CGt.itinr� !K/! 7y• s �^'%(c I�CPiurz
70 rtkf :u� e��r,<«runs
Mail Permit to: �i
What is the current use of the Building? X tf slrnrat
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? �/r S . Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's NameAFFaxdkbte 7$-2 -l'IWO
Address and Phone I f 7 mow, ;-r nA
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ $DC,CD — 1,iX19-cb Permtt Fee Calculation
Permit Fee$ 44� 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 /��/ %2
Date
0
.9
V
o V