9 GARDNER ST UNIT 3 - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
I MBERI.EY DRISCOU
MAYOR
120 WA.SmNGTGN$7AEET#$AI.EM,MA$SACnUSETlS 01970
TEL:978-745-9595 4 FAx:978-740-9846
APPLICATION FOR PLAN EXANIINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION
Location Name Building
Property Address q GA a n e S 004—
tE 3
Located in: Conservation Area Y Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3_114_
Residential(3 or more Units) R2 t,-
Type of improvement Residential(hotel/motel) Rl_
(check one) Assembly(Theaters) Al_
New Building_ Assembly(restaurants&clubs) A2r_A2ne_
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
Mercantile M_
Storage S1_Moderate Hazard
Storage S2_Low Hazard
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Name -'Q E-Fr zti D. Sm:K
Address 9 Cva ane r S* U44- -f:13
Telephone c1-71 d5H 39cii3
Signature9
DESCRIPTION OF WORK TO BE PERFORMED Ff�bV.. Ij bv✓ /1�S FL1�0 ti
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ESTIMATED CONSTRUCTION COST ��3
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
K ERLEY DRISCOLL
MAYOR
120 WASHINGTON STREET*SAIEM,MASSACHOSETIS 01970
'1Y+i:978-745-9595♦FAX:978-740-9846
CONTRACTOR INFORMATION
Name
Address
Telephone
Construction Supervisor's Lic#
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name Wer (jaryisiL-
Address q4 I un wwrS l- q"o-P�+W- S
Telephone 17 d 8 3G g I S v
Mass.Registration # 4 p Se/V�1 +� t ye G,30 //a
PERMIT FEE CALCULATION
Sg3 �
Estimated Cost x $11/$1,000+ $5.00= fu�A qj!� KAl r\
COMMENTS 11 ii /1 I
`/��"Q- h Ad- a &.1d tn)AS 4 2� a t1a C qV chip 0 b /,
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The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penalties ofperjury
Signed (owner) (agent)
APPROVED BY:
DATE APPROVED:
CITY OF SALEM
=llPUBLIC PROPRERTY
1
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U.
DEPAK"I'MENT
III ')',4 '4i 11X': ':'X.V_•1i4,.
Construction Debris Disposal Affidavit
(required lbr all demolition and rcnuvatiun work)
In accurdancc tt iih the sixth edition of the Slate Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal Iacility as defined by MGL c
111, S 150A.
The dchris will be transported by:
Did 5�bf
(name ut hauler)
I he debris will be disposed of in
(name ul Iacility)
laddres. ur tanlitvl -
'1 '11Jt OIc� (c111ult applicant
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