17 NORTH ST - BUILDING INSPECTION (5) What is ft current use of the Building? how many wits?
Material ofBuilding? it dwslYrmg.
Asbestos?
Wfr the BuIdhV Conform to Law? -
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ArchiOseCs NamS Q , ° o
Andres•"Phorw 30
Medwde's Name
Address and Phorw HIC Re&traftn mt
Construe supervisors License d
Estimated Cost of Projed Permit Fes Calu+lstlon
Permit Fee i Esdmabd Coat X$7I1111000 Residential
Es*nSWCostX:11/f1000Ca1mrrmereia�-
An AddMor d$5.00 Is added a•an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
,pwjWaticrms. signed under penally of perjury a
Date q
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C.rrTUF37ALEN -
PUBLIC PROPERTY
DEPARTM&NT
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71d M7454SM•PAZ M740.9e10
APPLICATION FOR THE REPAIR. RENOVATION QNSTR C TION
DEMOLITIOM OR CHANGE OF U3E OA OC['[TPANCY >QOo ANY g G
STRUCTURE OR BUILDMG
1.0 SITE INFORMATION
Location NNW SuildkV
Property Addrssw
V1
Properly is bested in a:Cwm v dm Am Y Hh1oA0 YIN
2.0 OWNERSHIP INFORMATION
2J Owner of Land
Name: �(��
Addrsae.
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EYISX=8u1LDINGs ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(so Renovated
construction or renovation
of existing building New
Brad Description of Proposed
2Work:
-- — Mail Permit to: ,1 -
AL CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Permltl kease ti
Issuing Authority(circle one)
I. Board of Health L Building Department 3.Cltyfrowa Clerk ti.Other I fltetrleal Inppector 3 Plumbing Inspector
Caataet Pawn:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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'rn:978-7454595 •FAX:978-74i,-9M
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 0 -_ . __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
jl (o �Gs
(name of hauler)
I'lie debris will be disposed of in
tname of facility)
(a.dress of Iac;liry)
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