2B SPRUANCE WAY - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERT'y
DEPARTMENT
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Attach a'copy of the werkeres corpewfba potley cite Lratlea Patter(attowly the -��-
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ngLhvd under Section 25A of MO[,a 1 Jt an lad b the Wsposiden of o�peaddes of s
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urnu'xoeo coverage verification
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city or Town
Issuing Authority(circle PermlNLltew I
!• Board of 111111111 2• uilding Department 1. Ctry/1 own Clerk i. fleetrleai Inspector 4 Other I Plumblag Inspector
Coatsci Prnoa:
CITY OF SALEM
1 `•�� PUBLIC PROPRERTY
DEPARTMENT
\l.t t'r`R 120 Vtt.\911VGi JN S i REET ♦SALF\t,MA4iAt:;LL.,L J-J S 0197:
TFt:978-745.9595 # F.%X:979-74G98i6
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:
,( 5�C'G.e l,, G
(name of hauler)
The debris will bed isposed of in :
t✓mz�^17 4e-
_.
(namr of facility)
210 �Iul� Kf� I�o� �_ p1, �o�Qcz A D'18Ga
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BOARD OF BUILD REGULATIONS
License: CONSTRUCTION SUPERVISOR
Numhe S 092119
f j BUIy_�q 08IO2/1965
s fi �
08I0?J2009 Tr.no: 92119.
ALEXANDER SAVCMENKO f G✓ ,
109 BROAD ST#'406�,�, „
LVNN. W 01902�--''. 'y Comm........ „
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PUBLIC PROPERTY
DEPARTMENT
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Nwvot 130 WA"UMW*rft !9 3ALN1�4Nb1GR:i►TIs 01970
'nL•M?45- "0 PAMM740.9W
APPLICATION FOR THE REPAIR. RENOVATIAIIL CONST-RU ION
DEMOLITION. OR CHANGE OF USE OR Q03MANCy Fog ANy EXISMG
UCTC�� OR RjaL G
1.0 SITE INFORMATION
Location Name: l3uiidlrlg:
Property Address:- 2)S
Property is klcated in a;Coraervallon Ana YIN Historic t)kmd Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: 2 $ S�?r raa y» lq/a� 9Q AeAr o1.;?.7o
Telephone: 97S 7 76'SSS
3.0 COMPLETE THIS SECTION FOR WORK IN E KWI1NG BUILDINGS ONLY
Addition Existing
Renovation ➢eeL Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation
Alt-
of existing building LL. New
8dd DeWiption of Proposed Work:
�,��oVo fic3t^ of 9ecL
Mail Permit to:
What is the Mrent use at the Building?
Material of Building? ItdwelW+g.how many units?�--
Will toBu�Conform to law? --- Asbestos?
Ardideds Nam* ( t —
Addrea and Phone
Med=Ws Nana
Address and Ptane 21 HiC Regisaation a 6 0I P 21
CWaWation Bupervisoa t.ieinse a
Estimated Cost Of Profs Permit Fee Calculation
' '�— Es*natsd Cost X=7J$1000 RsWwdd
permit Fee:
EsWnated Cost m
X i11/:1000 Canerda4 —..._ _ .
An Additional$5.00 a added as an
Admini **"charge.
Make sure that all fields are property aria te91:1Y+ruler to avoid deiarys In prac"Wni;-
The undws4pmW done hereby apply for a Building PwTrA to build to the above stated
tined
specificatbre. S under penally of perlurY
Date f6 Z 5 0
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