21 STATION RD - BUILDING INSPECTION I
What is the Currantuse of the Building?
v✓g� FAA Mr r G K dwelling,how many units?_ v
Material of Building? Asbestos? /"o
Will the Building Confom to Law?
QT.9 RIDOt� —
Amhdaas Name
Address
and Phone
-----------------
Mechanfds Name
Address and Phone 336 tilC Regis"llm 0
7� Construction Supervisors VC°nS°
permit Fee Caiwlation
Estimated Cost of Project i o0'0
('estimated Cod X i7/s1000 Residential
Permit Fee$
-- -. Estimated Cod X it tlilo0o Gommerclal----
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 dose hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date o 0 0
0
N
/ 0 s o
I
PUBLIC PROPERTY
DEPARTMENL T
Mwroa .
130 WAfH"GrCW DIME"•S"AK M&MAan3h1-M 01970
TU--9.1-743.9S"•FAW 97a.740.9W
APPLICATION FOR THE REPAIR. RENOYATi N CONSTRUCTION_
DEMOLITION, OR CHANGE OF USE ON OCCMANCY FOR ANY EW TING
STRUCTURE OR BUILnnvG
1.0 SITE INFORMATION
Location Name: BUkfing;
Property Address:--2 F-- -5TAT rOi.-j, Jp-C A:N -
Property Is located in a;Conservation Are@ YIN N Historic DW&W YIN N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ArQ07ELC/ V/
Address: .21 S rvN-r i Onj T-o A r,
5Ph M^ O 1 `(-� O
Telephone: (Q {e y - O - 68 -8 1
3.0 COMPLETE THIS SECTION FOR WORK IN EYISIING 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 I
of existing building New
Brief Description of Proposed Work:
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BRTHRLoor-. - atom. 'xzoeG Kt7 '�(� . tZC`x-07�Tro
e>¢ +TH ROo.,., . TKt Pt r-' b- l710ti Cb.. , -L
5 57� o.-
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3 eLcuw .
-- - - -- Mail Permit to:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I?C W.Y.91fNG:J2:S:REET •!L.LF%1.%f.%%U:'.LL +1:1 U%9/C
TF.t:9M745.9595 •F.Yx:9717.74COM
Construction Debris Disposal Affidavit
(required for all demolition alul renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 Cb1R section 111.5
Debris, and the provisions ofviGL c 40, S 54;
Building Permit N _ _ 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:
(llama of hauler)
['he debris will be disposed of in
WAMC of facility)
p f4cilay)
I
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