4B HART WAY - BUILDING INSPECTION (2) Cr=F cS�a I
PUBLIC PROPERTY
DEPARTMENT
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MAYOR 12O WmHINGToN S`r&E6r•c•K\tASSACHlYtM 01970
TEL-9711-74S-959S 0 FAIL 976-740-98"
APPLICATION FOR THE REPAIR.RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 1*'2 Building:
Property Address: 7—8 �J�f W q/
property is located in a; Conservation Area Y/N A J Historic District YIN—,&L_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: 61 S/C.
Address: _/ /7re�7` C X
Telephone: j" of_ y-4�7 _ f'
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation �f Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
&ief Description of Proposed Work:
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Mail Permit to: �, 6 a�6 ?r/ �� ✓ �?a. 6d��
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what is the current use of the Building? ( sir Niv
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone l )
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ , 00 Permit Fee Calculation
Permit Fee$ Estimated Cost X$71$1000 Residential
Estimated Cost X$11/$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 above stated
specifications. Signed under penalty of perjury X
Date
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Time_---Date Date K Date Estimate Came In
F Address c� I
Name_ 0—' �� (/�, / �� ��;s �,.,���l City
Home q 7F 7` ) 75S Work Cell
Color Levels—Age—OR—Gas—House Style
O.M.E. Water Leak R.T. S.S. Cap Damper Fuel Liner WS Liner
COMMENTS: 1
Rebuild /Tuck pointing Information:
Bricks per tier #of Tien Stepdown Total Bricks x 1.3 =M.C. Disposal Fee
Crown Rebuild Crown.Repair Flashing Replace Flashing Repair WP N/C
Brush Staging Stack Staging Add.Ladders #ofTechs Needed Total Apps
Liner Installation information:
Hot Water btu Input Furnace btu Input Total btu Input Firing Rate Efficiency
S.S. Liner Size x Top Plate Size_x_Kit Tee_Custom Tee Kit Cap_Cap Size x
Reducer Size—x—Increaser Size—x—Elbow(s) Extra Smoke Pipe
Add Supplies
T.S. D Size needed x 35' -50' Cable needed? Damper Handle Masonry Repair
Technicians Information /Instructions -
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Time Date Date Estimate Came In
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Address —r City
Home Work Cell
Color.Levels A=e OIl Gas House Style
O.M.E. Water Leak—R.T.—S.S. Cap Damper Fuel Liner WS Liner
COMMENTS: s� � ✓�� '^� —
Rebuild /Tuck pointing Information:
Bricks per tier #of Tien Stepdown Total Bricks x 1.3 -M.C. Disposal Fee
Crown Rebuild Crown.Repair Flashing Replace Flashing Repair WP N/C
Brush Staging_Stack StaginL_Add.Ladders #of Techs Needed Total Apps
Liner Installation information:
Hot Water but Input Furnace btu Input Total btu Input Firing Rate Efficiency
S.S. Liner Size x Top Plate Size_x_Kit Tee_Custom Tee Kit Cap_Cap Size x_
Reducer Size_x_Increaser Size_x_Elbow(s) Extra Smoke Pipe
Add Supplies
T.S. D Size needed x 35' - 50' Cable needed 7 Damper Handle Masonry Repair
Technicians Information /Instructions- -.
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