28 GREENWAY - BUILDING INSPECTION PUBLIC PROPERTY
DEPARTMENT
'-"�MAttAtHl:56TiS 0I970
To-976-745-gS"• FAx:97a.740.93"
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: r-1-. w Building:
Prop"Address---- ---- ---- ------ - - - ` - -
/ r--jai cui le
Property is located in a;Conservation Area Hlatorlo Distrlot YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land z5 ✓Lt/L'S 9 o S
Name:
Address:
i
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN ageTiNG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
/7 11P
--- - ---Mail Permit to: r r00
CITY OF SALEM
PUBLIC PROPRERTY
DEPARnAENT
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Are you piryer?Clack tb apprepelsis bencooftoWs -,—_
1. (&B tym�r pars-do ).6 o��do su �; 6' �'emeoeda.
2.❑ 1 as a ank pSwprlaon of paetaar. Hood on the attstchad Shutt ?. ❑Remodeling
3*and have me employaae Thee ani.00etraeamt have t ❑Dr®otkloe
weddas coop hamm"s.
( woeioa� ccaao* h J. ®in my capacity. W.we 9• �addtetom
ootpaeefts and in
3. l homeowner at�have exacins l thdr l D-0 Momieal repairs or additions
doing all work tight atumapdm pan M(S. 11.[3 plt1101bing cupans or additions
my nK(No wiorksa'camp, G. IJX 11(4),and we have no fi=U roe regained.]t empbyat Oft woeltss' 1 12.Q Othar�
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Irtwranea Company Name --
Polity N or UV-inL Lia.� Exp"doo Data• o
Job Sitt Addrsv
AttaeY s Sep of the werksra' eompatuaNee Polley dadaradon PaP(Slowing the pogey number and eaprratfee dab).
Fsihut to return en"P ae required uadar Section 25A of 1` M S. i s2 can lead ache' D�ttu Ofa
fine up b f"Moo
aod/ar anWyear ia+Pr{Sonment SS wan aS Civil Mine of er{mind
of up to J2So.00 S S pesldu to rba Corm bra STOP WORK ORDER mad a tine
Invest& e D t�tsu now' 9a veci d that a copy of this atatemeat may be forwarded to the Dtl1p of
gations of the DIA for r..,.�..,...eovenP vairlcadoa,
I do be et'cardA an<p tAe pek" aJ tAs�►.rw
laraeedon arovrlil absw 4 ow aw/eairrd
Of a of ate on/p'.DI Sod writs GS We area& ts be Cf up Ud y city w tstrw Oh*jW
City or Towat PermiULivasa
Issuing Authority(circle nays
1. Board of Htsith 2. Building Department I City/Town Cler
& Other k 1. Electrical Impector S Plumbing Inspector
Contact Person:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'All!'Kl.n l'!'Ki1k:U11.
\tAWK 12C W.\StIrXG'i0NS:REET • SALF\t, M.WNACbll.,LI-IS0191C
TEt:978-745.9595 . r.ax:978-7+G9846
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 ofMGL 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)
fhe debris will be disposed of in
7- of facility)
I❑(ki elf of tjlt1,t Y)
— ei_eaturo l ;>cnni[ app,iclo[ ---
9
L
What is the current use of the Building?
Material of Building? If dwelling.how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name .
Address and Phone ( )
aoF� L L
MechanWsName
Address and Phone L/jl r/+ lceI6a ,-j-U
Construclior► Superv's usors License# 071677 HIC Registration#
Estimated Cost of Proieat ` Permit Fee Calculation
permit Fee$ Estimated Cost X$7/$1000 Residential
_-, EstimatedCostX$11/$1000Coremercial------- -
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 a v s
specifications. Signed under penalty of perjury /�
Data L
of /
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