96 SWAMPSCOTT RD - BUILDING INSPECTION (4) - _ EITY--OF-SALEl- --
-� PUBLIC PROPERTY
DEPARTMENT
KIMBERLEYY DRISCOLL
MAYOR 120 WASHINGrON SIRFFr♦S ALkly,M.<isACHIStI'IS 01970
IFi 978-745-9595 0 FAI:978-740-99"
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: r1
Property Address:
l!
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: U 'T -
Address:
_ 'i � — � -
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EMWING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building? a -
1a r
Material of Building? �p --d- I If dwelling, how many units?
Will the Building Conform to Law?_
o S Asbestos? 1"G
Architect's Name A)Jk <Sn1
Address and Phone Ito
,n u F .
Mechanic's Name 1
Address and Phone ti
Construction Supervisors License# Go/�i / ( � HIC Registration#
Estimated Cost of Project
cniei Permit Fee Calculation
$�--
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An AdditionaL$5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to b 'Id to t abov s d
specifications. Signed under penalty of perjury
X
Date
t' N
O
t a
%)
a a
a u ,.
7 ka C*sm@ nptat(b i jM bnx((i
Depardtasstf ejlaltrs�rTit Aallarb
Ofat b�
6"WashbosAimsbew
BoW4 MA 02111
tnatttatdssrrltWds
workers'compeo.adas Insunnes Amaavtt:DidM WCantradon/Flecdida=Mkmben
lnnNt wef{b rasattoa Mean Pirbat I. mMy
Name
Iboaa f:
Are 1m am c$ee!tli,�m- WImW bW' �. _ T"e of pnbd QroN�dk
` f ��- tti 0/am a Basal ao.lra M and i
1.QLI m a eogbyer wbt,�_ dv ❑New osasseedoa
em9byees(Msed/tttpw$.dma)w bawbbedtltw
2.❑ 1210 a sots paten * -I f or patsa6 Nod aster sambd do&I 7. ®R—eaoddlsg
slut and tree as esswloyaa Tku nb-a oaetsta bsw L ❑ Demoldea
wodctar forteais aril `YO � . � 9. p BwIft sddhiom
gym.�',mntrasew s. we ats aappe�ddiysal i1r 1o.Q EMc.WW tepa3s or addi ims
otIIoai toys ' t�tr
3.0 I1mm a b meowum doing ale wade 11.13 Pbmbtea ttpdw or aadidom
aysaK(Na wadnei' ooa4• a i3O 12.Q Roornpahs
mswraaoa> r: Rla, ,- y 13.0 Omer
;AM qq k"60 cbm .eon n m d dim al 004@ Mays ".In qp aaap..ro.yatq ma*m.uow
Bmrarawar,a.raaar.atwivamaea�ea.—�dlrat�/L1�t# arirmaaa�asmwbaaaarydea..ai a"
eC,..�.euaatskmi�rrra ,m man ter ohm&AW*s.a erar =cook aaamw Glow ydby ma.mrja�
lar4�D�Jrb/^ "gr+a�r1�n4al�+� ad�IrdrpilgalfolaAAr
Ingursom Name 11-7
polity s at ScWior.Us, 467_ E*z.adoa Dasa �3 0 7
Job Sion Addtraa V-6 �.; r� ,� �� �/ /� City/Stitp/lip %4, /1-e 6L e
Ahab a WVP o(tbw Wortera'eonVoLudom pocky dedaradoa pap(abowbog the pWky■amber and espiradom date)6
Fan=to scene ooveraie s regained order Setttoa 23A o(bKL c. 132 tea lad to Ow rsspaii im of atmmal penaltim of a
law up to SI,5WOO and/or one-year b bommclO In wel U civl pmalda in the f m ors STOP WORK ORDER and a flow
of up to$250.00 a day apbst dew violates: Be advised mat a copy of dh ststemat my be f rwwded b dw Ofltce of
lavadlaooaa of ma DIA far ba more aovcmp vcdficadoa.
l V lrarly eadb / aJOer/rry dl�rba bJ«aswetowOivvrlr!abory tr uar aw!earrses
— L Z
O,Qleld am awfp Do nor wft In utb a"&,to dv coa+ofsul by rid drmm sj%Id
City or Towu PermWfletase 0
Inning Authority(drde oae)s
1. Board o(Htattb t Building Department 3.City/Town Ckrb 1.Eleetrlad Inrpedor !. Plumbing Inspector
L Other
•_ i
y " CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOIL
MAYOR 120 WASHINGTON STREET• SAIEM,%WSACHLSEn's 01970
TEL-978-745-9595• FAX:97&740-9&%
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 i 11.5
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:
6�G4-S� io /1 c`T S • c7`i_�S
(name or hauler)
The debris will be disposed of in :
e
-44
(name of faculty)
(address D facility)
nature of permit a ticant
-W1e 0—
Jehrisat7:dae