BP-82457RESIENTIAt ❑ Phased Approval (R106.3.3)
1.1 Property Address:
Contact Person: ��K/�l�1sicJ
Phone Number:
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:.:„
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number:
Map Lot c
1.3 Historical District ! ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Kevisea o i i.
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