3B GRISWOLD DR - BUILDING INSPECTION PUBLIC PROPERTY
DEPARnmNT
KDMERLEY UR15liO11
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120WASH S-raEEi.
INAK-,.�rASSACHl;55:l1S 0197U
- . TE•-973-745-9M•FAX 97&740-9846
APPLICATION FOR THE REPAIlL RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: i s/Zi.r A✓ PF?R K Building:
Property Address:
3 -f3 G-R55cualcl I�+2
Property is located in w. Conservation Area Y/N -A-J Historic Dieiriet Y/N _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address:
G
Telephone:
__ 9� 7 e/q j oo l/
I COMPLETE THIS SECTIONL FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation v� Number of Stories Renovated
Change in Use a New
Demolition Existing
Approximate year of Area Per floor(sf) Renovated
construction or renovation _._.
of existing building New
Brief Description of Proposed Work:
SEc IZi o 2. �'i 2� p rRGea r,S61—W.A "' `
1 •f-: IiFP: •
dr,f3l:J":Y'.;G. r_al5 i�i
- pA t4 __--__
Mail Permit to Pesbodv,MA 01960
978-977-9900
What is the current use of the Building? .--
Material of Building? _ If dwelling,how many units?- _
Will the Building Conform to l.aw?'4`- Asbestos?
T
Architect's Name he Cbimney Guys
Address and Phone
Mechanic's Name -
Address and Phone
Construction Supervisors Licensek HIC Registration#
Estimated Cost of Project:$ -5� Permit Fee Caak u!!ti!M
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 —'
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