5 FLINT ST - BUILDING INSPECTION PUBLIC PROPERTY
DEPARTMENT
KI\LL4FRI.EY DRISCOLL
MAYOR I-V WASHINGTON STREET♦SALI1K MA.SSACJHL;SLTTS 01970
TFi 978-755-9595 FAx:978-730.9"6
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: fij ,�—rz/ r s7hicee
5&XL it Q1g-7d - ?///
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land v
Name: As -7c s C T F llecF
Address: S X-'2/,1V—1 S 7'n��T!
Telephone: 9 - 7 VY - a 277 ?
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation 4. Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
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Mail Permit to: S Z J
What is the current use of the Building? DW f� 14416— n
Material of Building? L d oUO If dwelling, how many units? oL
Will the Building Conform to Law? x Asbestos? NG
Architect's Name
Address and Phone /� t a /mot G e�low
Mechanic's Name
Address and Phone
Construction Supervisors License# — HIC Registration#
Estimated Cost of Project$ 16CO ' Permit Fee Calculation
Permit Fee$ 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 6 N0(/.2006
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CITY OF SALEm
' PUBLIC PROPERTY
DEPARTMENT
w> CRUCOLL
r1AVOG 13S WAOUNG oM SrUM 0 SALE MAUAO 7 M o1lM
Construction Debris Disposal Affidavit
(required Cot aU demoMm sod r movatias worst)
In accordance with dw sixth edidoo of dw Sbts DuUnf Code.7W CUR section 111.5
Debrik sod dw pnwidons of UM a AA S 3%
BuDdiM Permit M is issued wilt the condition that the Mole moddna ft s
tMs wont sW be disposed of in a peope ft Uesnsed weep disposd bd ty as defined by MCB.a
1161.3150A.
-ri-A debriswiU be transported br
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(rims dhsalal
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The debris wiU be disposed of in:
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siaaa permit apOlicaot
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