30 WEST AVE - BUILDING INSPECTION (2) CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
\t.nrK 12C WAS]IIXG ONSrREET •5ALI'M. MASSAclu >LCIS 0197C
rE[:978.745-9595 • FAr:978J4Cr9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section t 11.3
Debris, and the provisions of vtGL 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 V1GL c
111. S 1.50A.
The d bns will be tra)spored by:
E to(-Orvy. )
1 name at hauler)
Tlu debris will be disposed of in
ErvT�l Ccll9Rl� ti'u
(name o✓facility)
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3
PUBLIC PROPERTY
DEP�'�RTMF.1�tT
MAYOR 130 WASUNGTCW SSMEW•SµEa,VAtdAOlLskl'13 O1970
Tau MUS-OS"E FAX M7404M
APPLICATION FOR THZ REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 8uildtng:
- -- F"perW Address: -
A vF
Property is located In s;Conservation Arss Y/N_fit_Historic:DIstrW YIN A., _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: R M O i2 /SSE
Address:
Telephone: 9066
3.0 COMPLETE THIS SECTION FOR WORK IN EYl8XIML,7 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 ldoo"7 N
Bde1 Description of Proposed Work:
�Ei33vlL �i.or.,T y� nirJ 13r9c K Sc! OF
--- - ---Mail Permit to: - -
What is the current use of the Building? Fit) k.i
Material of Building? 8 1 C t' If dwelling.how many units?--a —
Will the Building Conform to Law? �/C^S Asbestos?
Architeds Name
Address and Phone
Medmic's Name
Address and Phone
Consbuetion Supervisors Licanse 5 HIC Registration 0
Estimated Cost Project s =U 0 Permt F s Calwidlon
p=it Fee i a Estimated Cost X i7Ii1000 Residential
-- - - Estimated Cost $41/51000 Commercial'An Additional$5.00 is added as an
Administrable charge.
Melee 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 hove stated
specifications. Signed under penally of penury
X
Date ate - q' 07
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