1C FLETCHER WAY - BUILDING INSPECTION LEM
PUBLICPROPERTY
DEPARTMENT
I:I�LLIERISl OPIS(:Utt "-
�/ 130 WA%nNarm S "�raeEr�+ NASnau:st'rrs 01970
7/ / Tt 08-74S-959S 6 FAX M740-9U6
APPLICATION FOR THE REPAUL RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: G/�M Qn/ 10,912K_ _ Building-
Property Address: -_.
/-G
Property is located in a;Conservation Area Y/N .. l Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: -
Address:
f. -/eT -Ae le wA
Telephone:__.._- 19-7Y WO / .3`l
..-....... ..
3,0 COMPLETE THIS SECTION FOR WORK IN >�rtcrttut_ BUILDINGS ONLY
Addition Existing
Renovation �/ j Number of Stories Renovated
Change in Use I,j
ow
Demolition
Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation of existing building New
Brid Description of Proposed Work:
p � i►1. ' -�:u5 A/l-- mew
S°u.Pert,iaR •G'i2ep,�f.�y}�GEy? '��.t��tf''I? '
Mail Permit to:
Peabody, - -- -- .
What is the current use of the Building? -,
Material of Building? If dwe0ing.how many units?-
will the Building Conform to L Asbestos?
Architect's Name I PO.Boa 4074
Address and Phone Peabody,MA 01960
1 )
Mechanic's Name
Address and Phone ,-
Construction Supervisors Ucense# HIC Registration#
Estimated Cost of Project:$ -29SZQ= Permit Fee Calculation
Permit Fee$ U o Estimated Cost X$71$1000 Residential
Estimated Cost X$111$1000 Commercial
An Additional$5.00 is added as art
Administrative charge.
Make sure that all fields are prop"and legiblywritten to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build Jto the above stated
specifications. Signed under penalty of perjury
Date e� /Ff otf
Y
ii
4 u y=, C6