70 LORING AVE - BPA-08-942 SALEM STATE CITY
PUITfAC PROPf-A Y,
j DEPART\II NT
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS
[NII'OR'PANI':Applicants must complete all items on this page
SITE INFORMATION /e.�✓1
Location Name {e Building V,4,1���__
Property Address O Lo ✓e
Map# J�leM, mA 0197c)
Located in: Conservation Area Y& Historic district YiN
Use Groups
(check one)
Residential(3 or more Units) R2_
Type of improvement Residential(hotel/motel RI _
(check one) Assembly(churches) AI _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants,recreation) A3
Alteration Business B
Repair/Replacement_ Educational E_
Demolition ✓ Factory(moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2
Foundation Only-_ High Flazard 11_
Accessory Building_ Institutional (residential care) 11 _
Other(describe) Institutional (incapacitated) 12_
�.nfVib/' ,Sr!/ o✓>< Institutional(restrained) 13
Mercantile M_
Storage(moderate hazard) SI _
Storage(low hazard) S2_
OWNERSIIIP INFORMAION(Please type or Print Clearly) `
OWNER Name , kle"^ ft A C,/�C� e /
Address /dao% f o f rt7a�f7 OPVP/�ert� CGf
Telephone JV L4 e19f J;� r4lean rv►A 9/Y7
DESCRIPTION OF WORK TO BE PERFORMED 74yd.�- `Vddd . 1
. GCCO.n+d�w"� i rn GiteY /CCeijrin �T6✓72/rtG.-.�.
ESITNIA FED CONSTRUCTION COST 000 U v
CONTRACTOR INFORMATION
Name e�01,,X Vc�/on
Address `I( firu prtoh`. �Q 0/yo7t fq rwi .rn/+
Telephone 7P rfj?d �77�3
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION! p ✓l 1
Name ;5r 4 t e,114 /7ye�l, Tf c/
Address J3 /-, Jpf F++-1
Telephone 407 d ,' ?0dO
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $I1/$1,000 + $5.00=
ps o00 �-o
COMMENTS
The undersigned does hereby attest that all information stated above is trite to the best
of my knowledge under the penalties of perjury
Signed
Date a a
V
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