395 JEFFERSON AVE - BUILDING INSPECTION CITY OF SALEM
•i'' f� PUBLIC PROPERTY
DEPARTMENT
KI\(NFRIEY DRISCOLL .. ,
MAYOR 120 WMI-IINGTON STREET♦ SAIlM,AL\SSACHUSEI-IS 01970
TFL 978-745-9595 4 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: Building:
Property Address:
Property is located in a; Conservation Area Y/N T Historic District YIN _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
NLAddress:
T S• 3'�0
3.0 COMPLETE THIS SECTION FOR WORK IN ExE_1—cTiNG 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
of existing building New
Brief Description of Proposed Work:
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Mail Permit to:
What is the current use of the Building?
Material of Building? AW/7 If dwelling, how many units? '
Will the Building Conform to Law? VE3, Asbestos? J^/Q
Architect's Name '—
Address and Phone )
Mechanic's Name �
Address and Phone
Construction Supervisors License# _ HIC Registration #
Estimated Cost of Project$ r Permit Fee Calculation
Permit Fee $ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an.
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. _Signed.under.penalty of perjury- X
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CITY OF SALEM
PUBLIC PROPERTY
f DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGI'ON$IMZr♦ SALEM,MASSACHUSETI-S 01970
TEL: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
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
I l•�
signature of permit applicant
V- 3 -0/.
date
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