71 MARLBOROUGH RD - BUILDING INSPECTION �/-7 =D� . PUBLIC PROPERTY
DEPARThIENT
KISWENEY ORMCOIL
MAYOR 120 WASMNGCON S'RFEr SAUL.MAaUCHl56l1S 01970
I m-,978-745-959S 0 FNt M740-9U6
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: ? gip Building: j�ff' , q
Property Address:
Property is located in a;Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �7
Name:
Address: ✓� J '
Telephone: /
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 (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Ae -�
— - --- Mail Permit to:
-57
What is the current use of the B ild g? ` �---�
Material of Building? if dwelling. how many units?
Will the Building Conform to L
Asbestos?
Architect's Name �v
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# S 6,2--71V-1 HIC Registration#
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$111$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 t bull to the above stated
specifications. Signed under penalty of perjury X xi�,4
Date
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F •a o C7 � � Yo
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