9 MAPLE AVE - BUILDING INSPECTION VOhat 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 ( )
Mechanlds Name a a f L L
Address and Phone �) r/+
Constriction Supervisors License# 671677 HIC Registration# 6 • G
Estimated Cost f ojed S ��oU Perml Fee Calculation
Permit Fee$ Estimated Coat X$71$1000 Residential
Estimated Cost X5411S1000CornmerclaL---------An Additional $5.00 is added as an
Administrative charge..
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Peermit to build to the a v s
specifications. Signed under penalty of perjury X
Date o G
v1 n
x o y 3
a
1
1
PUBLIC PROPERTY
DEPARTMENT ��
U�01FJL6Y D�LSCIxl ��e'
120 WA94NGUW b'ME4T•&UAiK%L&%Aon;S1,17M 01970
1-0-976.74S-9S"•FAX 9W40.96 6
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: s Building:
Property Address:_ -—
Property Is located in a:Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land 1,17 91,
Name:
Address:
zftfs
Telephone: — G — 6's/ L
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 (so Renovated
construction or renovation
of existing building New
Bdet Description of Proposed Work:
---- ---Mail Permit to: t Z' oD i wco
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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prapiaasr or pera"F 11"d as the aeaebed ahnt t 7• ❑R.mod.lteg
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working for me b any capacity. wotkeee'comp,ieotaaoa.
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doing all wort right alasamp"per um 11.13 p =Pebto or addldom
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Policy M Or Salt Ins.Lie.M: l�G 6SS5 "0 Expiration Dan o
lob Site Addmw
Attack s eopy of the workm eompsasadoa pocky doclarad"pap(showing the pocky aumber ad ssylrndon daa),
Failtu"secure coverage se raW""d un
fine up to 31 TOO and/or one der Section IlA of 11ttiL a 132 can lead b the impodtlan of eriasind paaaleGa o!a
of up to 3230.00 a a y unpr{eoemenr`as wan as Civil pmultias fa the ram of A STOP WORK ORDE1t and a Age
f nveati f the viobum. Be advised that a copy of this saoem e forwarded ece may be to the Otllee o!
guiotr of the DIA for Lmuaaca covonp variAtuioa
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City w Town PeratfuLlceale M
Issuing authority(circle oae):
I. Board of Health 2 Building Department 1. Cl
6. Otbsr ty/row■Clerk 4. Electrical Inspector 3. Plumbing Inspector
Contact Person:
CITY OF SALEM
1 PUBLIC PROPRERTY
DEPARTMENT
\LtYCK 12Q Vff.\91INGiJN Si'REET 5.+u'!1, fit.\\.1.\(:i ll SL175Ci9P
TEI.:978.745-9595 #P.+x:978.74G78{6
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)
I'he debris will be disposed of in
�,Imr of facility)_
I�Illltc5a olful:�il V)
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