3C HALSEY WAY - BUILDING INSPECTION (2) _ C:IT�COFJxrEX .-
P MUC PROPERTY
DEPAR'I1rIFNT
�lAraa s +
130 W&Wb' M b'-r% r*sNJQk :st„s 01970
M&-9. 74"S"0 FAX 978.7.G.M6
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APPLICATION FOR THE REPAIR. RENOV N CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OC ZAy4 , FOR ANY EXISTING
STRUCTLRp OR BUILDING
1.0 SITE INFORMATION
Location Name: , �,luilding 3
- - Property Address:-
Property Is bested in a:Conservation Area YIN Historic Dbtrbl Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ,
Address: 3 J
Telephone: ? o
3.0 COMPLETE THIS SECTION FOR WORK IN EXIAT1NG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per Floor (sf) Reno
con vatedstruction or renovation I .
of existing building New.
Bret Description of Proposed Work:
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e CHIn
— r n RAY49174 --
Mail Peffnit to: Peabody,MA 01960
What is the current use of the Building?
Material of Building?
If dwelling.how many un'ds?�—
WS Use Building Conform to Lan jdnU ev ( rive _ Asbestos?
P.O:Box 4074
AmKdeas Name
Address and Phone
Meohanle's Name
Address and Pho" HIC Registration 0
ConsVucftn Supervisors License 0
Estimated Cost of Project= � Permit Fee CaleulaBon
Permit Fee f ^ �D o ESdMted Cost X S7/i1000 Residential
Estimated Cost X Si 1151000 Commends'----- -
-- - An Additional$5.00 is added as an
Administrative
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 X
of
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