236 JEFFERSON AVE - BUILDING INSPECTION (3) EI`f'Y-OFFAL
PUBLIC PROPERTY
DEPARTMENT F:I�MFRI.EY DRISL'OLL
MAYOR M WASHINGTON S7REEr•SUXK MtitncxLSL1-M 01970
'tFi 978-745-9595* PAY;978.740-9&%
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: Building:
Property Address: )36 Se sorl a G�
Sa�i`t ..�-ta. ca/yTo
Property is located in a;Conservation Area Y/N z-� Historic District YIN ✓'
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ;:70L7 __-
Address: ,Z3G r&v�
CVl9la,
Telephone: y17_ 837- S3Y7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING 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: Ae ,-row f► +T�or�i /`+aT J
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Mail Permit to: 11
What is the current use of the Building?
Material of Building?G If dwelling, how many units? /
Will the Building Conform to Law? ,YeS Asbestos? /yo
Architect's Name
Address and Phone ( )
Mechanic's Name 1-fi2 /ice /.Uv�✓ro.�ouS�Ci
Address and Phone
Construction Supervisors License# y HIC Registration#
Estimated Cost of Project$`S Za Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$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 the above stated
specifications. Signed under penalty of pedury
Date L9 c
O "J > ate+