HomeMy WebLinkAboutBuilding Permit #717-2017 - 16 FAULKNER ROAD 9/23/2016 C nirXDID
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APPLICATION FOR PLAN EXAMINON * -
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Permit NO: Date Received �9 w
Date Issued: I/ ----�—"� ` SACHUs�
IM PnRTANT: Applicant must complete all items on this page /o✓ D 9
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PROPERTY'OWNER �g a5 - 115 y h
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MAP NOCE~L: vA, ZONING DISTRICT'. `k Historic District 1. 'yes
<° Machine Shop,,Village yes, no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ><One family
XAddition C I Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement Assessory Bldg Others:
❑ Demolition ❑ Other
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Identitic.ition Please Type or Print Clearly)
OWNER: Name: �oVgIAS r1i5e L.V�giv� Phone:
Address: 1(6 FA v I kn tr OCIA
CONTRACTOR N,ame$. Plttine: � ,A k
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-Supervi'sor's Cons#ruc#, :License:
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4 .Ho 'me NImprovement`l.icense. Exp. Date
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ARCHITECT/ENGINEER Domla,5 LVdAin; AY-c i}CL,� Phone: (���. $6°�• 4-4VL
Address: l(, Fgulkyier Rod Noyl'h A;Al er. MA Olf)9S Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.eC PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 46, V00 FEE: $
Check No.: Receipt No.: �h�1
NOTE: Persons contracting hill 1117rc.f,istered contractors do not have access to the guaranty fund
grtature ofoAgen_V,Qwner ' r Signature,.of contractWi, .;