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011D FILLMORE ROAD - BPA B-07-647 EI`I' ©F ALE - -- PUBLIC PROPERTY -PC KMMERiEY DRISCOLL MAYOR 120 WASHINGTON,$TREEr ."' \fASSACHt;sErts01970 ,j TEL 978-7;5-9595•FAX.97&740.98" APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION, DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Building: /ri/�Mo izc Property Address: ll - p �i /l�-►o r�-z? 2-D Property is located in a;conservation Area YIN v Historic District Y/N�_ 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: e 2I of- Address: Telephone: 7 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation 1/ Number of Stories Renovated Change in Use o2 New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: The Chimney Gn -- --- - - -Peabody-MA 01960 -.— Mail Permit to: 978-977-9900 What is the current use of the Building? Material of Building? If dwelling, how many units? Will the Building Conform to Law ehimney ys Asbestos? Architects Name P.O.Rax 4074 Address and Phone Peabody,MA 01%0 978-977- Mechanic's Name Address and Phone Construction Supervisors License# HIC Registration# Estimated Cost of Project$ '�` Permit Fee Calculation Permit Fee$ Estimated Cost X$7/$1000 Residential Estimated Cost X$11/311000 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 l_/ /it� Date 2 I of N O w w y '3r E 00 C7 a `o LI 4 j r � 61 , � tf