50 FREEDOM HOLW - BUILDING INSPECTION _ CITY OF SALEM
' � PUBLIC PROPERTY
a �" DEPARTMENT
K1%(iF.RLFY DRISC0i1-
MAYOR 120 WASHINOTON S'IREEr♦SAL M,MASSACHGSEM 01970
TE1-978-745-9595 ♦ FAx:978-740-9846
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: e t �
�'/1,4 ,Y Building:
i`� a c
Property Address:
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �/f S �a 6 .57. / _ h
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation / QS�
of existing building - New
Brief Description of Proposed Work:
T
Mail Permit to: 0,4` ram`' 0 I o614' /6
What is the current use of the Building? 0 C' O J
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name /7
Address and Phone Z^A 1 G� �/ � 7 " `L p7hy7-1
Construction Supervisors License# / } HIC Registration# S y
Estimated Cost of Project$ 2pG. Permit Fee Calculation
Permit Fee $ /7 ,5— 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 abov t
specifications. Signed under penalty of perjury X
Date
QQ
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KHMER LEY DRISCOLL
MAYOR 120 wASHINGrON SIREET ♦ SALLM,MASSACHUSETI S 01970
'ILL:978-745-9595 ♦ FAX:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 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
in a properly licensed waste disposal facility as defined by MGL c
this work shall be disposed of p P y P
1 11, S 150A.
The debris will be transported by:
(name of hau
The debris will be disposed.of in
(name of facility)
/--
(addr3Yss of facility)
Alpal a of ntit ppli at
da[
dr6risafr.dnc
/2�.