003D HALSEY WAY - BPA-08-498 clim -or
PUBLIC PROPERTY
DEPARTMENT 5�
ra..eer.sYo�saxi ✓
wrae 130 WAMUOM 1N SnMW sAtyMk w%Annsrrs o1970
Ta.M745-fby•PAM V&740-04
APPLI ATIO 4 FOR THE REPAIR RENOYATIM CONSTrt>r>CI`ION_
pic OLMON,OR CHANGE OF U3E OR OCCUPANCY_ FOR ANY EXISTING
STRUCTURE OR ROLDING
1.0 SITE INFORMATION
Location Nance -celn4AL., 1'4eeBuU&W 3 Q
-
3 e Nac�ey �A�
Property Is boded in a;Caaw dm Ana YM H' -l la DWkid YM
2.0 OWNERSHIP INFORMATION
9.1 Owner of Land _
Name: C'6 4 d cti
Address:
3
Telephone: Z�7"7 Fy/
3.0 COMPLETE THIS SECTION FOR WORK IN MUSIWQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New.
Demolition Existing
Approximate year of L
a per floor (sf) Renovated
construction or renovation
of existing building New
aver Description of Proposed Work:
T�'/zep ge-e oeer/qce ir.e 7ri
The Chimney Guys
- —- —- --- ---Peabody,MA 01960
-- -- ---Mail Permit to• - - - - -
What is the carrot use o1 the Suild6hg?
Material of Building? ifdaroanq.h boom urhits?
Will the B A*v cawam to LaVIlI-h,- ch n93; LII c Asbestos?
/rthiLeda NarM P.O. Box 4074
Peabody,MA 01.960
Addre"and Phone
Medwoe's Name
Address and Phone
Cqa�orh gupervisatt l.ieense 0HIC ReghtraUorh 0
Estimated Cod of Project s � � P�m�il Few Calwistlon
Permit Fee i Estimated Cost X$71111000 Residential
--- . - Es*nated Cost X:41/$1000 Cammerda4
An Additional $5.00 is added a$an
Administrable charge.
Make sun that all fields are properly and legibly written to avow delays In processing.
The undanigned does hereby apply for a Building permit to build to the above stated
specineatimm Signed under penally of perjury -
Date
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V
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