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NOTES and Data — (For deportment use)
IV. IDENTIFICATION — To be completed by all applicants
Name Mailing address strcct, cit%, a,ld Stcrtc ZIP code Tel. No.
Owner or
Lessee
Builder's
License No.
t. l�
Contractor
3.
Architect or
Engineer
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to
make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction.
Signature of applicant j Address Application date
00 NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD — For office use
Plans Review Re uired Check Plan Review Date Plans By Date Plans By Notes
9 Fee Started Approved
BUILDING _
PLUMBING
MECHANICAL _
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Permit or Approval Check Date Date
Obta rued Obtained Number By Permit or Approval Check 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
Permit number
Building' /
Permit issued � / � 19�
Building
Permit Fee $ /a
Certificate of Occupancy S
Appr ved by: i
Drain Tile S
Plan Review Fee S_
TITLE
Crit� of Xort4all ytou
� � �lassaclfusetts
T f®ffire of the �ngptrtar of 'Puilbittgs APPLICATION FOR
Page Plot S/ ZONING PERMIT AND
BUILDING PERMIT
IMPORTANT — Applicant to complete all items in sections: 1, 11, III, IV, and IX. p
( 5 ZONING /)��
I• AT (LOCATION) �` �,V r. DISTRICT)yO
LOCATION INO.) (STREET)
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
N
II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D
A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking" most recent use m
1 ❑ New building Residential Nonresidential
2 ❑ Addition N/ residential, enter number 12❑ One family 18 ❑ Amusement, recreational
of new housing units added, if any,
in Part D, 13) 13❑ Two or more family — Enter 19 ❑ Church, other religious
number of units— — — — --> 20❑ Industrial
3 ❑ Alteration (See 2 above)
14❑ Transient hotel, motel, 21 ❑ Parking garage
4 � Repair, replacement or dormitory — Enter number
5 Wrecking (If multifamily residential, of units ——————— — -i 22 ❑ Service station, repair garage
enter number of units in building in 15 ❑ Garage 23 �❑ Hospital, institutional
Part D, 13) 16❑ Carport 24 E:] Office, bank, professional
❑
6 ❑ Moving (relocation)
7 ❑ Foundation only 17 Other — Specify 25 ❑ Public utility
26 ❑ School, library, other educational
B. OWNERSHIP 27 Stores, mercantile
8 ❑ Private (individual, corporation, 28 Tanks, towers
nonprofit institution, etc.) 29❑ Other — Specify
9 ❑ Public (Federal, State, or
local government)
C. COST (Omit cents) Nonresidential — Describe in detail proposed use of buildings, e.g., food
processing plant, machine shop, laundry building at hospital, elementary
10. Cost of improvement,,,,,,,,,,,,,,,, J�oe)V school, secondary school, college, parochial school, parking garage for,
department store, rental office building, office building at industrial plant.
To be installed but not included If use of existing building is being changed, enter proposed use.
in the above cost
a. Electrical..................... s, v e Q 'mil
b. Plumbing ..................... _.E�� /L/��''`''��� �"�•1 •
c. Heating, air conditioning..........
d. Other (elevator, etc.).............
11. TOTAL COST OF IMPROVEMENT $ GOO
III. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L;
for wrecking, complete only Part J, for all others skip to IV. D
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS f7
m
30 KMasonry (wall bearing) 40 ❑ Public or private company 48• Number of stories..............
31 ❑ Wood frame 41 ❑ Private (septic tank, etc.) 49• Total square feet of floor area,
all floors, based on exterior
32 ❑ Structural steel dimensions .....................
33 ❑ Reinforced concrete H. TYPE OF WATER SUPPLY
34❑ Other — Specify 42 ❑ Public or private company 50. Total land area, sq. ft. ...........
43 ❑ Private (well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
51. Enclosed ....................... r
F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL Q
35❑ Gas Will there be central air 52. Outdoors........................
36 ❑ Oil conditioning? L. RESIDENTIAL BUILDINGS ONLY
37❑ Electricity 44 ❑ Yes 45 ❑ No 53. Number of bedrooms..............
38 ❑ Coal
39❑ Other — Specify Will there be an elevator? Full..........
54. Number of
46 ❑ Yes 47❑ No bathrooms
Partial.......
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