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0003 COLUMBUS SQUARE - BPA-09-438 CITY OF SALEM PUBLIC PROPFIR Y Dl PARl ME:NT L UJRI RLI.1 INf b .ul 1. . I_'11\\.\il llSl•II IS\fill-.I.f * 1\Lli:�l,\L\��V.III al.I-I�II `I_II 4 APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL [BUILDINGS EXCEPT ONE AND'2 FAMILY DWELLINGS INIIIORTAN,r: z%pplicants must complete all items om this page SrrEINHgarolnTloN , w\a� 4y ao�e / Location Nali\e�;a..e-Ne�ucm/ �kcY �a:. i Building LQ �L ©Q f g Property Address Located in: Conservation Area Y/N \ Historic district APPLICATION DATE Use Groups (check one) Group Homes I23_R4_ Residential (3 or more Units) R2_ Type of improvement Residential (hotel/motel) RI _ (check one) Assembly (Theaters) Al _ New Building Assembly(restaurants & clubs) A2r_A2nc_ Addition Assembly (churches) Al _ Alteration Business B Repair/Replacement Educational E Demolition Factory(moderate hazard) F1 _ Move/Relocate Factory(low hazard) F2_ Foundation Only High Hazard H_ Accessory Building Institutional (residential care) 11 _ Institutional (incapacitated) 12_ Institutional (restrained) 13 1 Mercantile M _ Storage S1 _Moderate Hazard Storage S2_Low Hazard OWNERSHIP INFORMATION(Please tvq4) Print Clrarly) / OWNER Name _?,z_ k:0 S ocd Address- 3 W;h ,ter �s/a n� Rom Telephone 4�� 4tis 17v� Signature DESCRIPTION OF 1VORK TO BE PERFORMED L,rec 1I ICS"I'INIATF,D CONSTRUCTION COST y y CONTILACTOIt INFORNIATION Name Address % psi-° l yvyr-- Telephone "176 lz;7 9 i 4 L/ Construction Supervisor's Lic # � C��1 Home Improvement Contractor# /o`F `� G ARCIIITECUENGINEER INFORMATION Name Address Telephone Mass. Registration # old, Lq� l / yd PERMIT FEF. CALCULATION Estimated Cost x $11/$1,000 + $s.00- � y y a CONINIENfS The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge rrrrde penalties of erjury I Signed (owner) (accnt) rl APPROVED BY : DATE APPROVED: �O I� a g! ..... 479 } tiN % 0,As so 0 Ad) pGAN (566 0 rZIO Z V4 ry of CA 9/Z I- YE Y P4 SSOCIA 7 ir.5,14) TZ667r� A)YEIZ5 PLAN OuK )RIMAAA!eV IF WAS. Deir'04T OF lLSco 0 '4 19 1 CE/zr/py 'r, P(-AWJ EVrI7766-Pl 4. pig q-47 Lj: 4ccoeo,4A.)Ce kvl rjq -ryE IZUC65 sAj air, P;zaps-lerr wlcimm e- ;Y,4y OF 7-06 Z5j/SrE le 9, "A4. W1440W.1 'j 0 DEEDS �f� �(7 /922 CMU . 71,-r#OL alJOA/Z ED :49Y .1.45 A+ 4PP4 I.0 er, Met,