0012 CELESTIAL WAY - BPA-07-1130 us•of tM Building?
What is the currant use e� WOO it dweos how many unds?
Material o1 Bultdirng? y� Asbasloa? ' '`
W111 the Building Conform to Lavin
Archit S Nana ( t
Addre"and Phone
Address
Phone
supervisors License r d a-�-r 7 7 HIC RegistrationItConstructiona
Es*naW Cat of Protect PermN Fes Cala+laiton
PMmlt Fee i Edknaad Cat X$71:1000 Residential
melded Cat X$"Si1000 Co n wciat-- -
An AddNiww$5.00 In added Me an
Adrnktla mdw cl+ar'pa.
Make sure that all Mlds are PropwV and ably written to avoid delays In Droasdng.
The urKUn pry does Eby apply for a Building ParrAt to build to the above
�sta�ted
spwAmWn& signed under penalty of Pedn+rY
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s
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w CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
110 WAS)11V(-,i0NS.rREET •SALF\t.Nt.\1iACHL SL Fi 0197'-
Tel:978-745-9595 •FAN:978-74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 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 1.50A.
The debris will be transported by:
(name of hauler)
l'he debris will be disposed of in
Inamr of facility)
-- -- -- --
iaditress of facility)
-_- s nature of p"mit appiicaat --
:.ate
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Name 1 �G, 1/4u�c-
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ship sod bore ss ampbyer These (�DttmoiGtes
working be me is any capacity. werksw camp,kmmemaa
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Afaners3.❑ I homsoaraer doing an eroe6 tight of Mine sssmbd cite r 10.0 RlsoerlN rVdm or amass
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company Name:— / y
Policy M ar Solt isa Lek.ti C t�('00 f 3 7 G O
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Job Site Addmw oZ Geld-.�'q ( (OW16A y
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Athe6 a sop of tie srorkara'eompetesatbs palby dealdae��(e�wmg the Polley nambor and aap/rntles date}
Failure ro wane covaap as required under 3ocdos 25A of AM a 132 can ined to dw ta>oocitba of aimisal patesitlra oft
fins UP to!1,30g 0o tmd/a on♦year imprisonmaeR r weH ar eivB Pin k dy form of a STOP WORK ORDER and a fine
of up to$230.00 a doy spies the vklaw B.advised the s copy of thin stanmrm may W forwarded to the Otlioe of
Invc:sdptioss of the DU far inj r wvrmp verifleark.
/do hereby cod ands a4Pei"and pewaNw olperiwy A&ub/s
,rwIv,(_ `� lor+saaletsirorl/afahem 0"a"ear"
C9 1
Phone 0-1 7t-( c)y C�
OQkld nra WA De nos WHO Gw utb area,At be coev w by cup orleaae opjw
City or Town:
PermltR.lteete p
ItsuWng Authority(clrcls oak
1. Board of Hesith L BuUdiog Deputmtat 3.Ciry/fowa Clerk 4. £lecirieal inspector 3.Plumbing laspaetar
tt. Other
Coataet Perna;
o�.._A.
i
PUBLIC PROPERTY
`1 DEPARTMENT
Www �3owewuw�w sn�ar•
�r►w.�aa:Lnsotrn
TX.MN& M.FAel7W�69W
AlM.ICATION FOR THE UPAIA R2tOVATiON ON TI UCON .
DEMOLITIOM OR CHANGE OF USt OIR rp�" FOR ANY M a L ,
1.0 SITE INFORMATION
Location NUM
Prop"Addresr.
Prop ft In kxx+Isd In a;Co wa vedon Arne YM 1 v Hlstab ofsblot YM
f20 OWNERSHIP INFORMATION
21 Owner of Land
fVame: �✓�.� �:� Ce-�'�n:
Tetephon.. �% 7" 0 7 i
3.0 COMPLETE THIS SECTION FOR WORK IN Et18LNVNew
Addition
Renovation Number of Storie
Change in Use
Demolition
Approximats year of Area per floor(sq
construction or renovation
of existing building
Slid Description of Proposed Work:
l
- - - Mail Permit to: -