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es,,4 ...0%60 Application forr'(a Permit to Build No. L5-1/UPON FINAL APPROVAL �>Tl"l j MAP `d LOT yl C7
FEE MUST ACCOMPANY THIS APPLICATION. DATE9
The undersigned hereby applies for a permit to build �/��D
according to the following specifications \ ()
1. Name of property owner -\oe.�,t,_ O E<.,Y Tel.
Address _ 3is' Yl14f\a5..)4.r Q1, t.J. fra 4L
2.Name of Architect(ifany) ` Tel.
3. Name of builder 6SikK F..�. o.-! s1 Address
4. License No. 1 T .
5. Name of Masonnak •h:t< ;z'c c1i4ist Address &it 24.4
2r o ti
6. License No. 1541473 lel. 1-5?oc - 6 1i- 101 3
7. Construction address .'S' P14.1Ct. .atr La t(whn,, ,,4
Flood District
8. Date of subdivision Approval plain zone Zone
9. Private dwelling p Estimated Cost DO NOT WRITE IN THIS SPACE
Type of room No.
10. Multi family 0 &000 .a 441/4PJ; l
L i..5 010 I or Kitchen
11. Commercial ❑ �1,�lF(us �vm,uaY `—S
12. Other ❑ � � Dining Rm.
13. No. of stories KIL 41 Living Rm.
Bed Rm.
14. Foundation — Full 0 Half Q Crawl C" Slab 0 cra.7
Bath
15. Materials — Wood ❑ Cement 0 Other 0 Deck
16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0Closed porch
p'/)Cat �� FamilyRm.
17. Garage - 1 0 2 Sun room
18. Swimming pool - Size Garage
19. Storage shed — Size Shed
20. Stove —Wood 0 Coal 0 Alterations
21. Size of lot: No. of feet front No. of feet rear No. of feet deep
22. Size of building: No. of feet front No. of feet side No. of feet rear
23. Distance from nearest building: Front Ft. side Ft. side Rear
24. Distance back from line or street From rear lot line Side line
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LOT RELEASED BY Signature VTheC
PLANNING BOARD Address
Date
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