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, 0 a 6C Application for a Permit to Build No.
UPON FINAL APPROVAL 11 ' �b- MAP LOT
FEE MUST ACCOMPANY THIS APPLICATION. DATE fly 19
The undersigned hereby applies for a permit to build /0/9D
according to the following specifications
.lame of property owner 0-a-c- 'e rre SE:./6."V - Tel.
Address 62 / Ca 're - Sr y,o.4.70la rN-o tr, 7 - o-e47%"
2.Name of Architect(if any) Tel.
a Name of builder _Address
4. License No. Tel.
5. Name of Mason Address •
6. License No. Tel.
Construction address av cs .'rE.e• Sr Y.9 e mo �rN PO ¢ s O sear.mss"
Flood . District
8. Date of subdivision Approval plain zone Zone -
9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE
10. Multi family 0 ',Soo Type of room No.
11. Commercial 0 Kitchen
12. Other 0 Dining Rm.
13. No. of stories Living Rm.
Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 qe
olfr9A9
Bath
15. Materials — Wood 0 Cement 0 Other ❑ Deck
16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch
17. Garage - 1 ❑ 2 ❑ Family Rm.
Sun room
18. Swimming pool - Size Garage
19. Storage shed — Size Shed
20. Stove — Wood 0 Coal 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
•
LOT RELEASED BY Signature ✓ - e- ---c4 '
tr
PLANNING BOARD Address �y -
Date , 2..a� 0dle7s-