21 REAR ABORN ST - BPA-08-2061 REROOF CI'rY Or SALEM
PUBLIC PROPER I"Y
`. DEPARTMENT
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT I AND 2 TAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION
Location Name Buildin¢
Property Address... -
Map# ��-II /!'/^� A r AAA O lq-7Q
G 7�� A rX1�A1 �T
Located in: ConservaYmn. txa ft --tttstone dismet YIN
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential(hotel/motel Rl._
(check one) Assembly(churches) Al _
New Building_ Assembly(nightclubs etc) A2
Addition Assembly(restaurants,recreation) A3_
Alteration_ Business B_
Repair/Replacement_ Educational E Demolition_ Factory(moderate hazard) Fl_
_
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard li_
Accessory Building_ Institutional(residential care) II _
describe) Institutional(incapacitated) 12_
C 9 jTV7 Institutional(restrained) 13
Mercantile M_
Storage(moderate hazard) S l_
Storage(low hazard) S2_
OW N%RSRIP INFORMATION(Please type or Print Clearly)
OWNER Name aTER MAf-
if—JARD
Address A[[fin/ ('�L)!2i_ �`Zi4LEM MA 0/970
Telephone
DESCRIPTION OF WORK TO BE PERFORMED
�Q�PLAGE RME
ESTIMATED CONSTRUCTION COST
CONTRACTOR INFORMATION
Name
Address
Telephone
Construction Supervisor's Lic#
Home Improvement Contractor#
ARCMTECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
�i
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed
Date