5A GRISWOLD DR - BUILDING INSPECTION (2) -r-- - CITYoF3 O
PUBLIC PROPERTY
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MAYM 120 WASMNGTM SnwFffr 0 '�a4 4wstlatlsk-1'rs 01970
TM 978-745-95"•FAIC 97e.740.90"
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: Building:
Property Address:
Property is located in a; Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.i Owner of Land
Name:
Address:
S r9
Telephone: YZL�'- J'77 �cic*
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING 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
9de1 Description of Proposed Work:
The Chimney Guys
P.U. ox 4
Pha3,, MA n1own — -- — —
Mail Permit to: - 978-977-9900
What is the current use of the Building?
Material of Building? It dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name The Chimney Guy s
P.O.Box 4074
Address and Phone reabody,
Mechanic's Name nos o^r� Donn
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project S �� Pernit Fee Calculation
Permit Fee S Estimated Cost X$7/51000 Residential
Estimated Cost X S11/$1000 Commercial - -
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
F
The undersigned does hereby apply for a Building Permit to build to the above stated
k:
Xspecifications. Signed under penalty of perjury '
Date 3 �
YI
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