30 WASHINGTON SQ - INCORRECT ADDRESS CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIUBERLEY DRISCC
MAYOR "- � tv, 120WuSHINGTON SIRFEr*SALLMo(ASSACHl:SL1-M 01970
TEL,978-745-9595 ♦ FAx:978-740-9846
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: p W r ,(.� Building:
Property Address: /
Property is located in-a; Conse ation Area Y/N . t-1' Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: �
/ `z s
Telephone: -- -' f
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 New
Brief Description of Proposed Work: /
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Mail Permit to:
What is the current use of the Building?
Material of Building? �/ If dwelling, how many units?
Will the Building Conform to Law? / Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name c f n -
Address and Phone CC/
i4 /ern y /lam SS
Construction Supervisors License# 62/ F 7 HIC Registration# _/06
Estimated Cost of Project$ Ir-60 O 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 build to the above:st d
specifications. Signed under penalty of perjury X i
Date
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