19 SALEM ST - BUILDING INSPECTION C_1 L Y O1 J AI .ADI
APPLICATION FOR PLAN b 1r% A'f1ON AND IIUIf.DING 11111,1011T
ALL STRUCTURES EXCEPT I AND 2 F+111L Y DWELLINGS
IRIPOR I ANT:APIllicants must complete all items na this page
SII'E INFORMATI?N
Location Name A -f Building___.
Property Address /�
Map 4
Located in: Conservation Area Y/N -,_--,Historic district Y'N_-
Use Groups
(check one)
Residential(3 or morn
Type of improvement - Residential (hotel/motel RI
(check one) - _ - Assembly(churches) Al
—
New Building - Assembly (nightclubs etc) A2
Addition - Assembly(resuaurants, recreation) A3
Alteration. Business R
Repair/Replacement_ Educational E_
Demolition Factory(moderate hazard) FI _
Move/Relocate _-...__ Factory (low hazard) 1'2_
Foundation Only, High Hazard It
Accessury Building Institutional (residential care) I
Odper(describe) Institutional(incapacitated) 12—_
_ Institutional(restrained) 13
Mercantile NI
Storage(moderate hazard) SI _
Storage(low hazard) S2_
ON NERSI111'INI.Ourtl A'I ION(Please t)pc or 110ut Clearly)
!�-ccN/}s c G /h
OWNF?R Name _ieaoo
Address /9 S�lpu1 C I— _
fclephone 3zs-
F
ES('RI I'I ION OF RY)R6 TO RE PERT ORM ED —
i
F.SI-UTA I ED CONS HO („ON (-OSI y. --------- - --- - --
- -
as_ � o
P r
l
CONTRACTOR INFORMATION r1
Address f
Telephone ;1%128 6 6 /
Construction Supervisor's Lic # O(may 7gZ7/
Home Improvement Contractor # /ZO la(eO
ARCIIITECUENGINEER INFORMATION
Name
Address
Telephone
Mass. Relaistration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $l l/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury,—).
Sign `
Dare 0