17-19 SALEM ST - BUILDING INSPECTION CrrY-OF-g-AL .
' PUBLIC PROPERTY
DEPARTMENI T
KIMHOUXYDRISCOLL
MAYOR 120 WASHINGTON STREET•S ALk14,MA]SACHI:Shl15 01970
1FL 978-745-959S• FAX:97&740-9&M
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY Y EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: _
I-?— �
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _ tl
Name: l 1
Address: _
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building I
New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use gf the Building? -I-
material of Building? g•
how many units?—
t1�� If dwelling.
Will the Building Conform to Law? 2 T Asbestos?
Architect's Name
Address and Phone
Mechanic's Name �—,-L
Address and Phone [ G a�
Construction Supervisors License# C(� HIC Registration#
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ c -IL-IL—IL—IL9 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 tzf],�t
'lid to the above„stated
^`
specifications. Signed under penalty of perjury X
Date 9 I
0
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N
F_ 3 4 a G� a9i e
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