4D HALSEY WAY - BUILDING INSPECTION �/�� _off EIZ'Y-OFg
PUBLIC PROPERTY
DEPARTMENT
KMAU N"ONSCUIL
V►rae 130 WAOUNGTM Mm♦s 4 o�srrs 01970
TOUM7454M•FAM M7404 M
APPLICATI- N FOR THZ REPAIR RENOVATION CONSTRUCTION.
pENJOLTTION.OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTIIVG
STRUCTURE OR BUII. MG
1.0 SITE INFORMATION
Location Name: � C C-,--7 cam - rum;
---- - - -
Aron Is www in a;Caroanation�/m YM Hisioric Dtsm YM
2.0 OWNERSHIP INFORMATION
2.i Owner of Land
Name:
Address.
Telephorw: —/` J C� gc�3
3.0 COMPLETE THIS SECTION FOR WORK IN E7I9IWQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change In Use New
Demolition Existing
Approximats year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Sdd Description of Proposed Work:
The Chimney Guys
Peabody,MA-01.960
--- _- ---Mail Permit to; - -
What is the current use of the Building?
Materid of Building? If dwelling.how Many units7
wm the sumo Contom+to ey kuYS Asbestos?
Ads Name
Address and Phww Peabody MA 01960
978-977-9900
Medartk:'s Name
Address and Plans
Construction SupaNism License 0 HIC RegMMti*t 0
Estim w Cod of Project: Oc'�' Pemdt Fes Cawuwon
Pena Fee i Estimated Cad X$7/$1000 Residential
-- - - - Estimated Cod X$11/31000 C mmwda4---_._._
An Additional $5.00 Is added as an
Adminw&a&o darge.
Make are that an fields we propsrht and legibly wrmw to avoid delays In processing.
The undersigned doss hereby apply for a Building Per7,-,,7
above stated
spec&,adons. Signed under penally of perjury
Date
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