3A HALSEY WAY - BUILDING INSPECTION (2) CITY-OF-
PUBLIC PROPERTY
DEPARTMEINT
MAYM I W Wwut+Gww h'ctm•SmAjK MAmAojLshj-rs 01970
To--97L74S-9S"t FAX 978-740-MU
APPLICATION FOR THE REPAIR. RENOVATION,CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION j
Location Name: &dkong:
property is located in a;conservation Area YM N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: e` r,-- '
Address: 3 A 1/o,,Islam
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN E) IIIIII G 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:
olc/ )qr;;01Cz
-- - ---Mail Permit to: Ci6t-2:g _40 ac ye ct�� --
What is the current use of the Building?
Material of Building? If dwelling,how many units?
Win the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanie's Name
Address and Phone UL ✓� x Ci�7c1 /2 v
Construction Supervisors License# HIC Registration#
Estimated Cost of Project i Permit Fee Calculadon
CIO
Pennn Fee S Estimated Cost X$71$1000 Residential
Estimated CostX S41/=1001)Cornmerciat----------
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 a above stated
specifications. Signed under penalty of perjury
Date 6
N
YOI
V
V
1
96
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