4C HALSEY WAY - BUILDING INSPECTION OF
P P R®PERTY
FDEPARTMENT
wroe 130WASU GTCMbw •sk+Kwuuaasr,�s81970
11r:M7464S!!!i•PAw M7409W
APPLICATION FOR TBZ REPAIR. RENOYAn-o ['omg 1cnori_
D&MOLITION.OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING_
STRUCTURZ OR BUILDING
1.0 SITE INFORMATION
Location Name: r'r 8uildlr
Property Addrew-
Property le koceted in s:Conaervallon Area YIN /./ Hhftft tlWft YIN-
2.0 OWNERSHIP INFORMATION
11 Owner of Land
Name:
Address:
y_G
Telephone: - �9 -- S '7.7
3.0 COMPLETE THIS SECTION FOR WORK IN F UILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in iJse Now.
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation
of existing building Now
add Description of Proposed Work:
�2nnUx
The Chimney Guys
tleabody MA 01960- — . ... . - - .. -... -
--- -- ---Mail Permit t0: 978-977-9900 -
What is the cuff"use of the Building?
Material of Building? Itdvwuirq.how many unitaT
WW the BuadkV Conlbnn to t.aw? ?
The rmney
Atdoteds Name
Address and Phon0 Pn+.6ndV MA 01960
Meehank's Name 978-977-9900
Address and Phone
ConsbuctIM Supervisors t.lcwm 0 MIC RegWMW B
Estimated Cod of Projed: J✓ Penra Fee CaMub*n
Permit Fee S Estimated Cod X$7151000 Residential
EsWnatsd Cost X:411:1000Cormnaalal-- ---
An Additional Sam is added se an
Administrative charge.
Make sure that an fields are property and k4bly` ~to avoid delays to processing.
The undersigned does hereby apply for a Building Permit to build cJ�
stated
specMeadom Signed under penalty of penury
Date
S ��`
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