95 PROCTOR ST - BUILDING INSPECTION (2) -- CITE`BF�ALE ----
//y PUBLIC PROPERTY
DEPARTMENT ((�
91SOFAI.EY DRISCOLL v
MAYOR
120 WASIiIIVOTON$1RFEr*JAI.FIM,,,l1SA(HL561-IS 01970
1Fi 978-745-9595♦FAX:978-740-9W
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
'7- � T
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATIONe,flh h f
2.4 Owner of Land
Name: 9C `L L yc
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation ^ Number of Stories Renovated
eo
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
,/2ew av-c q 2�
Mail Permit to: Y c�
What is the current use of the Buildi g?
Material of Building? If dwelling, how many nits?
Will the Building Conform to Law?_ Asbestos?
Architect's Name 4 �N
Address and Phone _
Mechanic's Name Y
Address and Phone
Construction Supervisors License#— � -HIC Registration#- &1241�
O K ermIt Fee Calculation
Estimated Cos Pro�eot$�
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
l
specifications. Signed under penalty of perjury
Date
� � bl
O
w+ a
i u
• CITY OF SALEM
• PUBLIC PROPERTY
DEPARTMENT
KIAa4ERLEY DRISCOLL
1?t1WtiH
MAYOR INGTON$'tRFET#SALEW,�'�CHCSETIS 01970
I'Ei 978-745-9595• FAX;978.740.9M
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# 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
111,S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(mane of fulllty)
(address of facility)
)5tamsriamrc
of pemtit applica, t
date
1
drhrismT.duc