0010 BLANEY STREET - ADD TO EXHIBITION DECK �t✓Mts [,
What is the currant use of the Building? 7
Material of Building? Z�& If dwelling.how many units?_ r
Will the Building Conform to Law? y�S Asbestos?
Architect's Name
Address and Phone
Mechanic's Name �^ 40
Address and Phone
Supervisors License# HIC Registration# —
Construction 'P`3 boo Permit Fee Cakulatior
Estimated Cost of Project ii— Estimated Cost X$11$1000 Residential
Permit Fee: -
- Estimated Cost X V 11$1000 Commercial------ - — -
e An Additional$5.00 Is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of perjury
X �
Date �� G
i
96
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CrrY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
LUSH M aru000u.
au� tIO.asamrwnprasttttar.sun411attnattsttsoi97'0
Tn.•97W45."n a Ptob 9 w,*9Nd
Workan' Comptmaadon Inurna AfNav* BlWdw WCo
plan Pflug Loodbly
Names
Addmsa:_—1
City/StatdZip: �f�y yS r��9 �+/yo�ghone N 7 9/ 7 l 9 f-f 5-
An you a aaphayer!C%O*ehs approprlsft ben
1.13 I as a esttpkryw with I, p I am p a owd conersew and I Type of project
ataiployoee(Adl anwcr pa"11140 have hired do S N*w co°mO
2.R I wm a sole preprletw or pssmeo- listed an the atteobed sheet t 7. ❑Rasoodsnag
ship and have no employan Then snaaamsaton have L p Demondon
working for me he any capacity. wakeea'camp'moomem
(No worker'camp minnance !. p We are a corpossai n and ite 9. p Buildingaddttloe
required) otllamr haw eamelaed their Io•p Eleatried mare at adman
3.0 1 ans a homeowner doing all work right of aamtptim per MIX 1 l.p Phrmbing mpsise at adman
myaelt(No worker'aomp, a. 1S2.!1(41 and wr haw no 12.p Roof repair
t0 �)t emv�DID work®' 13.p Otte
gyp.hwaaoor meukad)
;Any 4Vmar dat dmb bee Of mar an a am de.action bdoe Andy tlekaarkns•owfoundon
Name ftme6 cbmkdikbasnalditedwd aaddwdsaYaaa..k.trek.array . N.dt
rco.a.aaea ar bmk dla bee mar:tmeb.d r.dabta.d Baer deadaa da m�a orda aoMcoararar aad drt waakwa•arms, tda�raWM
rya ItprovtOGj worbas'co+epewroelow Wwaweifor eery'rarpfoye&A Rckw/r de poft etef fey siv
Insumucs Company Name: A '//1Q
Polity 0 or Self-ina.Lia.lF. NC Expiration Dw
Job Site Addraw PIA Ciry/Stete2ip
Attach a copy of the workers'wmpstaudon Potley declaration Pap(shswblg the Policy somber ad explrntion data)6
Failure to secure coverage"required under Seetfoa 25A of MOL c, 152 can lead sa the WVcwd m of crimiosl penaldoa of a
fine up to$1,500.00 and/or one-year imprisonment,as wen as civil penaldp in tht loon of a STOP WORK ORDER sad a Are
of up to 5230.00 a day against the violator. Bs advised that a copy of this statement may be forwarded to the office of Investigations of the DIA for insurance coverage varideado4
I do k4rel cord&undies,tbepebar awd pewaMN of per/rup dW the Gforarasiow PMv1ded above It a w as coma
Phone M:
Of�efd wse oafp De cod wrfb In this arts;to be rowpfeW bl cfry or tows a,Qk/a!
City or Town: PeratibUcase y
Issuing Authority(circle one):
L Board of Health 2.Building Department 1.Cltyfrown Clerk i. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone q•
i EI-i�r-oFg -
PUBLIC
PROPERTY
DEPARTNLF��IT
1:L':idFJCh1bRLVA L
130 WASMN W 3ttt=•
. &UAC+lSO-M 01970
74t 97/-745-M•FAx 978.740.98"
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: S, i,w, f , Suilding:
Prop"Address:—
Property is located In a;Conservation Area YIN Y Historic Dietrkt YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land GdY G�Soli^^
Name: 1,G7�v G✓ ,a
Address:
Telephone: 741jr-- IFS 5S
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New f
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: Mal
— --- -- Mail Permit to: