118 WASHINGTON ST - BUILDING INSPECTION (6) PUBLIC PROPERTY
DEPARIVEINT
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MAroe 130 WA-%UN M��r- &ntrx MAMAan;sci'rs 01970
1E1.979-745-9595 6 FAx,976.740.96"
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EMSTINCI,
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address. 1\g L.4. Xwat bt-• l kv.,k L
S o V w• AAA 019--0
Property is located to a;Conservation Area Y/N Al Histarlc otsirld Y/N
I
2.0 OWNERSHIP INFORMATION
2.1 qpr$► l� 7 it/A-i17' l5 friA-V1 T r
Name: RG& LLG Ll.0
Address: t—A-0 lJct XV� SI- Sck` �t A ZG wAP67 ib'."s
C>11-4-0 Go11V6LJ--1WPe-- aj fir/
Telephone: OnOfo ' 6.(7^G(o'1^?vl1
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing -.
Renovation 7( 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
Bclef Description of Proposed Work:
/:? N6 fL ors S
A-jQ t> oFF I GE /A/ ,1=X(G7r a/6- lZ57Ae -
Mail Permit to: c 7`LGpi�y�
What is the current use of the Building? STh
Material of Building? �Y �G� It dwelling,how many units?
WiU the Building Conform to Law? y�
Asbestos? No
'CP •/ t.0 i DYL b oy.anv� i�
p,rchited'a Name,,,
vY
Address and Phone l7 '�vat oo
Mechanic's Name
2 O�-�� V1L,lgd&c
Address and Phone j
Construction supervisors License# 051 D 80 HIC Registration a d5V 7 a
Estimated Cost of Project S dOQ Permit Fsis C"Iatiort
permit Fee i��— Estimated Cost X$71S1000 Residential
Estimated Coat X S11/$1000 Commerclal -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 ¢1 t th ab vs stated
specifications. Signed under penalty of perjury
Date 1/
J
NI
O � �
MM
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CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'TS(ENT
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Construction Debris Disposat AfRdavit
(requtrd hr an demolid"and twovad"wotlt)
in uconlatta with the dxdf adidon ddo Sate 9uUb*Code.7W MIA soctioe 111.S
Debris,sad dw ptovisiow of MCL a 406 9 Sk
9uildis4 Pon+ie e _ is isasd wilt rite eondidon that the debris reaidns!teas
,his wort shall be disposed of in s Pc*Pw1Y licensed waste disposd fbcility as deflaed by WIL e
1II,Sis"
The debris will be eranspottad by:
_ tnam arhadd)
fhodcbds will be disposed orin :
(,UAAW of fs►d,ty)
I o(D So�te�in \
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