5C HALSEY WAY - BUILDING INSPECTION CITY-OF-3
PUBLIC PROPERTY
�' DEPAR'ItitE,�1T 96b
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MAYM 130 WASIUNCMW 3'1lF *]AUsk NAYSAC.11t5tl'IS 01970
TS--976.735-959S•F=975.74&96M
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BIJMDING
1.0 SITE INFORMATION -
Location Name: &<OBuilding: ('
Property Address:
Property Is located in a:Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _ q
Name: E% o
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN "ISIING 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:
e�—
The Chimney Guys
Box 4074
Pe2hod„ M4A41960 - -
Mail Permit to: 978-977-9900
what is the current use of the Building?
Material of Building? If dwelling, how many units?
will the Building Conform to Law? Asbestos?
The Chimney Guys
Architect's Name ox
Address and Phone_ 0eabody, A44 0]gfin ( )
Mechanic's Name 978-977-9900
Address and Phone
Constriction Supervisors License# HIC Registration#
Estimated Cost of Project$ ���' Permit Fee Calculation
Permit Fee$ Estimated Cost X$71$1000 Residential
Estimated Cost X 911/$1000 Commercial _. .
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 the above stated
specifications. Signed under penalty of perjury X
Date �L o
N
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,N,tP1 I