10D-030 (6) •
IV. IDENTIFICATION - To be completed by all applicants
Name Mailing address — Number, street, city, and State ZIP code Tel. No.
I . ( 617) NOTES and Data - (For department use)
Owner or Richard Caparso '38 Strand Place. Southbridge. eia. 01550 765 -0234
Lessee President
Fairway Village
Buils
2. George H. Beu License No. izR_ - ' 5 !%
Contractor 0
Suoerintendant Same as above 015126
3.
Architect or — ' ''
Engineer 1,4 �ls�e -cam. / Qdf �' � : �� ."-- CC7 -z.0 y
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to �/
mak:,this application a is authorized agent and we agree to conform to all applicable laws of this jurisdiction.
Sig r - re of applicant Address Applic tionl,
3L Strand Place /13�
• /. /'�_- Southbridge,a.
00 NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD - For office use
Plans Review Required Check Plan Review Date Plans By Date Plans By Notes
Fee Started Approved
BUILDING $
PLUMBING $
MECHANICAL $
ELECTRICAL $
OTHER $
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Date Date
Permit or Approval Check Obtained Number By Permi or Approval Check Obtained Number By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building. r ..., ,. Use Group
Permit issued - ).'i ( �� 19 '
Building Fire Grading
Permit Fee $ 1 -2(K Live Loading
Certificate of Occupancy $ Occupancy Load
Appro by:
Drain Tile $
Plan Review Fee $
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