BP-92639a
Applicant informed of above: Date: Time: Clerk:
Comments:
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit [sued to: ,,-44t-i/ °
1.1 Property Address: 21 bLIV i e'. el'�4 IWA) 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map ✓ ( Lot -
Required Provided
Front Yard 1:3 Historical District ❑Yesrn
Side Yard
Rear Yard Year Built
❑ Altering more than 25% per side of buildiing
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic 0-ommission?
0 Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Date:
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