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WpZC=PWR TO A.P.EB T 9FJNG GRANTED
CITY OF_SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroo , tall Sidin tract Deck, Shed, Pool,
Repau/Replace, er:
PLEASE RLL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
spectficativns: Q
Owneea Name
Address B Phone
Archftect's Name
Address & Phone ✓�/� /� ( 1
Mechanics Name
Address & Phone 2
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Signature ofApplicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO:
No.
APPLICATION FOR
PERWT TO
LOCATION.
PERMIT GRANTED
APPROVED
OR OF BLKDlNGS
e�TY-ems �
1 �tSOa PUBLIC, PROPERTY
1-10 WASHINGrON S1REEr DEPARTMENT
MAYOR
"'`�,�r.�wcHt:sti-IS 01970
1Ei 978-745-9595 0 FAM 978.740-9W
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: Building:
Property Address:
Property is located in a; Conservation Area Y/N ✓ Historic District Y/N ?
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 4046
d ,✓,¢
Address: /& •F✓o-
1044- e 6le-4 a
Telephone: 78 !- &,-B CI -
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
r1emclition Existing
Approximate year of Area per floor (sq Renovated
construction or renovation
of existing building I New
Brief Description of Proposed Work:
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Mail Permit to:
What is the current use of the Building?
Material of Building? wa v/✓ If dwelling, how many units? 3
Will the Building Conform to Law? cs Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration# �� O✓Fa0
Estimated Cost of Project$�; aRe-1 Permit Fee Calculation
Permit Fee$ �Gl]' Estimated Cost X$7/$1000 Residential
Estimated Cost X $11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly 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 penalty of perjury /�
Date = e c-C-
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