7A FILLMORE RD - BUILDING INSPECTION EITrOF
If PUBLIC PROPERTY
lw DEPARTMENT
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APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR B1ILDING-
1.0 SITE INFORMATION '
Location Name: i SuddkV
- -- Property Addrasa -- -
�� �-i fry
'4 Property Is located In a:Conservation Area YIN HkrloAc Obbid YIN
2.0 OWNERSHIP INFORMATION
2J Owner of Land
Name: C ) /1/`e-f
Address 7 rc�
Telephone: � 9'77� OU
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDING
S ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use !� New
I Demolition Existing
r Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
The Chimney Guys
P.O. Box 4074
—---__ _-- 478477-4000 --
Mail Permit to:
What is the Current use of the Building?
Material of Buikting? Itdwelling.how many nunits? -
"it the Building Conform to Law?The Chimes-- =INS Asbestos?
Architect's Name P.O. Box 4074
Peabody, MA ft
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License M - HIC Registration 0
Estimated Cost of Projed i /2 So �' Permit Fee Calculation
Permit Fee= Estimated Cod X$7/51000 Residential
Estimated Cost X i411111000 Camrnercid------ -
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fleids are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to above stated
specifications. Signed under penalty of perjury /-
Date s
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