1D FLETCHER WAY - BUILDING INSPECTION PUBLIC PROPERTY
DEPAR`I1�IENT
3UvoR 120 WAStHMGTON Srx =*&U&K.1AS4ACKMTM 01970
77 142-97&745-9S9S*FAX 97&740-9846
i
APPLICATION FOR THE REPAIX.RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE'OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: p ,clemAj R K_ Building: - ,p
Property Address: /-6 F/e-Tchea wA(
Property Is located in a:Conservation Area YIN
_,AJ Historic,Disfrict
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land .
Name: l 2e.uc e e_ J
Address: _
Telephone:_ Cl .7 Sol
i COMPLETE THIS SECTION FOR WORK IN EXISIuura BUILDINGS ONLY
Addition Existing
Renovation r/ 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
add Description of Proposed Work:
p�2e:4,AJ4- O/II - e Al.,i .
f ;r i N3 i. Y1
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Mail Permit to:
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What is the current use of the Building?
Material of Building? If dwelling,how many unds?. _
will the Building Conform toAsbestos?
}e mney ays
Architect's Name .
Address and Phone PeahndyiA n1%O - I )
978-977-9900 _ -
Mechanic's Name _
Address and Phone
Construction Supervisors Ucense# HIC Registration#
Estimated Cost of Project:$ ,:20001' Permit Fee CalcuI IGn
Permit Fee$ U Estimated Cost X$7/$1000 Residential
Estimated Cost X$111$1000 Commercial
An Additional$540 is added as an
Administrative charge-
Make
� - written to avoid delays in Processing-
The
Make sure that all fields are properly and legibly
undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of Perjury
Date 1�/i <v5
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1 y �
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