24 WISTERIA - BPA What is the current use of the Building? �n�
Material of Building? l -
ifdwelling,how many units?
�---- ,
to aw? e N
� } _ Asbestos? o "
Will the Building Conform
Architeds Name 1 ( )
Address and Phone ` A
Mec wigs Name 2A �� 3 ��F � o 3 S f 3
Address and Phone Z
g C S U5_ 3�1(3_HIC Registration ft
Conabuction SupetyISOM ucena
ly o Permit Fee Cakuiatbn
Estimated Cost of Projed 5__,.
i Estimated Cat X S71111000 Residential
Permit Fee f _
- Estimated Cost $"'$'000 Commercial
An Additional$5.00 is added as an
Administrative charge.
Make sure that all aside are properiY and legibly wntten to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
spea,cations. Signed under penalty of perjury
Date
i � JJJ
� b
g w
a a e
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\l.ai+R 122C WA9 HNGGi ON S:'REET •SALPM.MMSAG R.11,1 I i 019/C
TEt.:978-745-9595 • Dix:978-74098-t6
07
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
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:
(name of hauler)
The debris will be disposed of in
OF
- " (nameuffacility)
-
I•Address of iiy)
anature of panic appiipm
,:ate