3-D HART WAY - BUILDING INSPECTION CITY-OF-S-ALEM-
PUBLIC PROPERTY
DEPARTIMENT
KIMBERLEY DRISCOLL
MAYOR 1?0 WASHINGTON STREET•J
ALUK 51A>.5nC3i1;5E175 01970
TEL*978-755-9595* FAx:978-740-9M
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: 3- 3 l-( mA,.6 (-,.-)c y
Property is located in a; Conservation Area Y/N M Historic District Y/N _1
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land t s a r
Name:
Address: 5
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIq1ING BUILDINGS ONLY
Addition Existing Z
Renovation Number of Stories Renovated
Change in Use New
Demolition F-Asting
Approximate year of Area per floor (sf) Renovated 9 to .S l=
construction or renovation
of existing building New
Brief Description of Proposed Work:
IZcPIa � � k, s IDS k-
Mail Permit to: '4- cYesr
What is the current use of the Building?
Material of Building? W a o-� =If dwelling. how many units? f
Will the Building Conform to Law? X eS Asbestos?
Architect's Name N
Address and Phone n'
Mechanic's Name
Address and Phone
Construction Supervisors License# 01 IS 6 HIC Registration#
Estimated Cost of Project$ .�
U vo Permit Fee Calculation
Permit Fee$ fz 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 X � -C -
-1 -0 ,
Date
N
y
F e C7
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