9C FILLMORE RD - BUILDING INSPECTION EI'I'Y-OFg11r.F1�
PUBLIC PROPERTY
DEPARTMENT
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w.ae 130 WAUUN W anuar•1w1K ,.,,:01970
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION.
DEMOLITION.OR CX4NGZ OF USE OR OCCUPANCY, FOR ANY EXIS L MG
STRUCTURE OR BUII.DING
1.0 wm INFORMATION
L =*m Nast« �/ 8uildM
Property A ---- _- --
Property Is located In s;Conswvadon Mee YIN Hlslorlo Olsolet YM
2.0 OWNERSHIP INFORMATION
2J Owner of Lanai
Name: o
Address:
Teki *xm: 7YV ��3
3.0 COMPLETE THIS SECTION FOR WORK IN E7t1871Np BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use NOW
Demolition Existing
Approximate year of Area per floor (3) Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
The Chimney Guys
4874
Peabody, MA WSW-
Mail Permit to: - ---
What is the current use of the Building?
Material of Suiidlg? If dwe&i&how many unit?
win the B a**Contb'to LawT a ChimneY GuYs Asbestos?
Architect's Name
Address and Phone 978-9 7 7-9900
Me Ot960 ( 1
MecIMM a Name
978-9
Address and Phone
Construction Supervises License 0 HIC Registration 0
Estimated Coat of Project ice=-�� Fe!Cala+htlon
Permit Fee S Estimated Cast X$71$1000 Residential
_-, Estimated Coax$11/f1000Corrunerdai�------ -- -
An Additional$5.00 Is added as an
Administrable cherga.
Make sure that all flelds are properly and legibly written to"old delays in processing.
The underslgned does hereby apply for a Building Permit to bui the above
stated
spwilicawm Signed under penalty of perjury
X C/
Date -
CL
AE
9 9
_ � 'Ric) -