0055 HIGHLAND AVENUE - BPA-13-693 1
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75 li 0 1 \S 9-1.-.III ')8.10
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DIYELLINGS
V,111OR I AN 1: :%pplicants must complete all items on this to•r
SI'1'li I I ' 1I,1 1'I�N 11_ L / — ul yy 1 t �r �I
Location Name �i C-1") 1oSp1' -1 Buildin /f h
Property Address I�f 7 b�lcte� S71ew1. ..
Located in: Conservation Area Y/N,Ar Historic district
APPLICATION DATE 1140(YA 1 /,
Use Groups
(check one)
Group Homes R3 _ RJ
Residential Q or more Units) R2_
[(check
ye of improvement Residential (hotel/motel) RI _
one) Assembly (Theaters) Al _
ew Building - - Assembly (restaurants& clubs) A2r_A2nc_
Addition Assembly (churches) Al
Alteration - Business B
Repair/Replacement_ Educational E
Demolition_ Factory (moderate hazard)- FI -
Move/Relocate Factory(low hazard) F2_ _
Foundation Only High Hazard 11
Accessory Building Institutional (residential care) - 11 _
Institutional (incapacitated) 12
Institutional (restrained) 13
Mercantile - M _
Storage S1 Moderate Hazard "
Storage - S2 Low Ilazard
Ow.NERS111P INFORMATION(Please lype or Print Clearly)
OWNER Name /1/�1' t S1avVY YhCu(�t 1 GPyr}eY
Address 81 1=h a nn L AV-e
Telephone
Signature
uESCRIPTION OF WORK TO BE PERFORMED - .
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E.SIIINIATEI),CONSTRUCTION COST C2—
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CONTRACTOR INFORMATION
Name
Address Sf1 ) 70j�j 4ye-
Telephone JW-39L1—?9�2a-
Construction Supervisor's Lic #
Home Improvement Contractor #
ARC111"1'EVUENGINEER INFORMATION
Name Re,&P-t-etlre. 4Yta -i
Address 55 GV AiG S-►-
Telephone y78 —35 _a
Mass. Registration # _YEC) ____
111•-ADMIT FEE CALCULATION
Estimated Cost x $I U$1,000 + $5.00=
CONINIENTS
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
wider the pet lt' of perjr
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S'igtted (owner) (agent)
(owner)
APPROVED BY :
DATE APPROVED: