40 LEGGS HILL RD - BUILDING INSPECTION pum-1C PROPERTY
DEPARTMENT
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: :% pflc:mis must complete all items on this page
sai,, INFORMATION . w�
Location Name40 4Z60� HILL 12P Building lyissi / ymeA- poo L—
I
Property Address
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3 124_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants &clubs) A2r_A2nc
Addition Assembly (churches) A%�
Alteration _ - Business B_
Repair/ Replacement_ Educational E_
Demolition Factory(moderate hazard) FI -
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard it_ ,f�
Accessory Building Institutional (residential care) 11 t6
Institutional (incapacitated) 12_
j Institutional (restrained) 13
Mercantile M_
Storage Sl _Moderate Flazard
Slora2e S2 Low Hazard
OWNERS11111 INFORMATION(Please type or Print Clearly)
OWNER Name �-;Jfol e
Address
Telephone
Signature
DESCRIPTION OF WORK TO BE PERFORMED
!;2 pLS a NPO"L J- "rQ00(Z Poc)ls
+ rtel.Ita GQ"1O Got 6-COUCC;T 0—
ES"FEW%HA) CONSTRUCTION cost O //-Nw- {� O
CUN'1'IL(C'1'014 INFORMATION
Name P �+
Address
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCIIITECT/ENGINEER INFORh1ATION /L _
Name
�0.r �7(0� �
Address
Telephone
Mass. Registration #
11ERIIrr FEE CALCULA•rION
Estimated Cost x $l 1/$1,000 + $5.00= O
CONINIEN•rs .
The undersigned ap i tit does he attes at all information stated above is true to the best of my knoWedge
under the penalt' s o perju
Signed (own (agent)
APPROVED BY :
DATE: APPROVED: