39 FORT AVE - BUILDING INSPECTION Enwr-OF
v PUBLIC PROPERTY
DEPARTMENT
I:�.R1FJt1"6Y oRucwt
MAYOR
120 WAsmNcroN Snw"•S_;M AAACHLstI'rs 01970 \�
TEL 978-743.9595 6 PAX'978-740.9946
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
SM-A CTCrnF OR BUILDIN
1.0 SITE INFORMATION
Location Name: �v Z Building:
Property Address:
Property is located in a; Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name:
Address:
% Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN PYIRT NG 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
Bcief Description of Proposed Work:
Mail Permit to: --
7
What is the current use of the Building? If dweik�`�many units?�---
Material of Building? `�`� Asbestos?
Win the Building Conform to Law? —
ArchitecVs Name I )
Address and Phone
Mechanies Name
Address and Phone HIC Registration#
Construction Supervisors License#
Permit Fes calculationEstimated Cost of Project S — Estimated Cost X S71S1001) Residential
Permit Fee$ Estimated Cost X$111$1000 Commercial
An Additional $5.00 is added as an
Administrative charge-
Make sure that ail fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to Jb'uiild to the above stated
Signed under penalty of perjury /�
specifications. Sig
Date
0
I "
N
01
a
a � s
-