36-171 (2) PERMIT APPLICATION CHECK LIST
PAGE S(Il PLOT I ZONE -3 V/',-- - YES NO DATE
1 . ZONING FORM APPLICATION o k
2 . PERMIT APPLICATION �-
3 . OWNER OCCUPANT STATEMENT LIC . # IF NOT
4 . 3 SETS OF PLANS PLOT PLAN
5 . NEW CONSTRUCTION
r
6 . CURB CUT
7 . WATER AVAILABILITY FORMS
8 . REMODELING INTERIOR
9 . ADDITIO
10 . ACCESSORY STRUCTURE
11 . SIGN AWNING
2 . PERMIT FEE - CHECK ONLY - MONEY OR D R
13 . SPECIAL PERMIT REQUIRED WITH DEED IF APPLICABLE
14 . UNDER SECTION 127 - CMR 780
15 . FORM A
16 . FILL
COMMENTS :
a �
IT
'3 }bier catrrltrrre!ls o _ .. ,
N A
w DEPARTMENT OF fl)Uff.Df?JC; INS!'i;C'i'IONS
INSPECTOR 212, .11Th', Slr et. Xlurricil:ral ltuildin
Nortlurrnpto;i, Afass. 01060 '
FIJEA, BURNING APe'LIANCE, & (.HIMN1 1` APPLICATION PERMIT NUMBER
1'l c t. 1 Zone _
Location
Owner or Lesser _�'�4 �����_ , _ 7-3 /
(M^,3.) .i atlY: Address)
e:>s) (TeLa. No. )
(Nip,.,) (Addri�ss) (Tale. No. )
RESIDENTIAL NUN-RESIDENTIAL
tic Business
—�O t
Two or Mars Others
Numbs-. of ltni. s Specify
Storir-; ii: B"ildim�
Type_ of Appl.ianr.e
Neva .._.�Wood burning
Used Coal,
I.aheLt�d Combination
pate of Purchase Other
Specify �.
,. Model or Type _�Lin IAJ( t n
Mhnufac tore*
Purchased From _
(Name of Firm)
(Address) � —
Cost - Construction & Appliance
Chimney V_ New •� Metal Bestos
Existing interior chimney
_ Separate Flue Exterior chimney `•
Other Appliance attached to 6,111 ,
�y Masonary Lined
Unlined
Notes & Datz: �(
Signature of Appli ant: _• �.3/ (1-ki.ce
/' (Address)
Approved By.
Date
Title: �Se _
ptiw PT
Date Filed /Q 00035G File No.
ZONING PERMIT APPLICATION (§10 . 2)
`l1 Name of Applicant:
Address : 3/ Telephone:
2-Z Owner of Property: Gu SS !e
Address : Telephone:
3 . Status of Applicant: l ,-Owner Contract Purchaser
Lessee Other (explain: )
4 . Parcel Identification: Zoning Map Sheet#_(v Parcel#/7/ ,
• Zoning Districts) (include overl J
Street Address �� e_
Req fired
5 . Ex ' tin Pro d b nin
Use of Structure/Property
(if project is only interior work, skip to #6)
Building height
%B1dg.Coverage (Footprint_ )
Setbacks - front
- side R L R
- rear _
Lot size
Frontage
Floor Area Ratio
%open Space (Lot area minus �~
building and parking)
Parking Spaces
Loading
Signs
Fill (volume & location)
6 . Narrative Description of Proposed Work/Project: (Use additional sheets
if necessary)
UV VVZA-
7 . Attached Plans : Sketch Plan Site Plan
8 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
Date: !d Applicant IsSignatur
THIS SECTION FOR OFFICIAL USE ONLY:
Approved as presented/based on information presented
E a ied as presented
fo nial:
gnat o Buildin spector Date
NOTE: issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning requirements and obtain all required permits
from the Board of Health, conservation Commission, Department of Public Works and other applicable permit granting authorities.
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