21 FLINT ST - BUILDING INSPECTION (2) ������ PUBLIC PROPERTY
�� '�" DEPt1RTMENT
KIMBERIEY DRI5(:OLL
MAYOR 1-V WASHINGTON STREET SALF1J,MASSAQ1l:$E"1lS 01970
'[fit 978-745-9595* FAx 978-740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: a �- eS Building:
Property Address:
d ! -//7 f
Property is located in a; Conservation Area Y/N Historic District Y/N ;
2.0 OWNERSHIP INFORMATION
2.4 Owner of Land
Name: t . r I,,
Address: i f/ f S / S 4 ��7
Telephone: �) & 7 / �-
3.0 COMPLETE THIS SECTION FOR WORK IN Exigllmr. BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
�oo F An
Mail Permit to 56 ��
What is the current use of the Building?
Material of Building? ✓ If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name ✓�
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# 07/ 6 7) HIC Registration# 6 ��
Estimated Cost of Project$ S OOo. Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 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
Date
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