25A MARION - BUILDING INSPECTION EYI'Y OF
PUBLIC PROPERTY
DEPARTMENT
HArw 130 WASUNGTnu TMEET•3Aunk.%L%UACH"kTM 01970
Tw M7464M•FAw M7404M
APPLICATION FOR THE REPAIR. RENOVATION CONDUCTION
DE.rI0LM0-&OR CHANGE OF USE OR OCCUPANCY FOR ANY XXRQFMG
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Locadon Name: tluildtrlg: -q-5eq
----- .
asp
P uMV Is located in a;Conservadon Ares YIN HIslaft District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address:
�Jrrq j�yZG/Lcd�l�
Tom.
3.0 COMPLETE THIS SECTION FOR WORK IN EXUMNQ BUIUMNGs ONLY
Addition Existing
Renovation Number of Stories Renovated
Change In Use New
Demolition Existing
Approximate year of Area per floor(sf) Renovated
constructlon or renovation
of existing building New
add Description of Proposed Work:
The Chimney Guys
4074-
Peahody,MA 014fi0 -
--- -- ---Mail Permit to: _ _ - - --
What is the emrent us*of the Building?
Material of Buitdit? itdwelling,how many u?
Will do Buffing Conform to Law? ���
Ardtitsd's Name The Chimne Gu s
P.O. Box 4074
Address and Phone ,
Modmm%Ws Name
Address and Phone
Construes Supri"am License 0 HIC Registration 0
Estlrnabd Cod of Project i/ Pa "Fam CsWulstlon
Permit Fee= Estimated Cod X:7/s1000 Residential
Esti nated Cod X$41151000 Cmmnwdmi
An Addiffonel$5.00 Is added as an
Adminiatradve dtarge.
Make sure that all Holds are property and legibly written to avoid delays in processing.
The undersignad does hwaby apply for a Building�P[wn**too build to am above alated
specftatlom Signed under penalty of perjury ^ �
Date
H
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o Jr