169 MARLBOROUGH RD - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M%1i;FKLEY Dtt ISCOU
\'L"Yolt 120 WASiINGTONSMEET •SALIN, 6'(AS5ACI-It:SE:CIS0197G
Tr[:978-74 9i95 ♦ 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 wil I be transported by:
(name of hauler)
The debris will be disposed/of in
nor It .Cll.f 0� SR/
(name of facility)
(address of facility) +pt
si la1
date
1�.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ttae.aatavtan�coti
MAYOR
120 1V,2016rw,frees?a Satan,X&gA0ft,WM 0lW0
TRU 97L743-959S a FAX M7
Workers' Compensation Insurance Atgdavit: gyildeyCoatneWryE)IKti{�ayphombers
A
Name� �; L an
Address: FO /3e x ? 7
eityfstataimp:_�iQ y -s . �l9 01g z3 Phone N E 7 5
An you"employer?Check the APP10"to boat Type 1.❑ I am a employe with 0 4. ❑ I am a genteel contractor and IFL
fgdrs d):
emPloy�(1iti1"at pat•time).• have hired the utb.Cohmwmramctioes
2. I am a sole proprietor err partner. listed on the attached shaft t
ship and have no ampktyeee Then haw wed dM for me in any capacity. workers•COMP,iansam a
(No workers,comp.msurancs J. ❑ we ate a Corporation and id dition
required.3. ] o9lu n have exercised their
I 10.❑Electrical repairs or additiaN
❑ homeowner doing all work right of exemption per MOL 11.Q Plumbing repsin as addition
myself.(No workers,comp• c. 132,f 1(41 ad we have no
insurance required,]t employees.[NO workers' 12.(]Roof repairs
comR insurance required,] 13.❑Other
'AnY wt+WcaW dW dWb bra el mwt des nt as dW r. dc.betom sbr dae edr erakata•oovyredya f y��mr�a r timuoeasu vbe euhdt abut slDdrrir a�g dry a doisd eg oak��kb
tCaaaecsoe 20 cheek dds ban emrt of aw re ddidmd Am show ias dr am of dr nbak'°^r' "k
eakeos comp•POW fabresedam
f ams am smsPloya that 4 Pro vhling workers'componsadom huaraaeejor my
injormadom err Ployssa Below Al AdPollry and fob SAW
Insurance Company Name: 6 h e
Policy N er Self-ins.Lie.N
/ Expiration Date:
Job Site Addreya / y /� rr � r o c
Attach a copy of the workers'eon uados CirylState/Zip;�/��
pa PO�y daehtndoa page(showing the Polley number and eaphraden dot$
Failure to secure coverage as required under Section 25A of MOL c. 132 Can its d to the imposition of crimiaai penalties of a
free up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
la es to 5230.00 a day against the ante or. ra advised the a copy of this statement may be forwarded to the Ofilm of
Invesdgationa of the DIA for insurance coverage verification.
/Jo herby c ratJj d r the and psnaldes ojPaJmry chat the le o j rmado"Provldsd above 4 bmo and entrant
Phone Ak 7� - `�33 7 /7 -
o leld vie om/Jr, Do not write In thht area,to be comrPleed by elly or own o lela(
Cityo r?ow
a
Permit/LiCeare N
Issuing Authority(circle one):
1. Hoard of Health 2.Building Department 3.City/rows Clerk 4. Electrieal inspector
S.Plumbing Inspector
Contact Person
Phone N•
BOARD OF BUILDING REGULATIONS
j License: CONSTRUCTION SUPERVISOR
j Number:. CS 081392
Birthdate: 05/31/1967 �I
Expires::.05/31/2007 Tr. no: 11572
Restricte_Ai 00=
JAMES C WRIGHT -
PO BOX 237
HAMILTON, MA 01936
Commissioner i
M1` ✓�ze -lOmrivrxoaxuieal/�i o�'✓1%�,a,wac/u�aalta
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 148520
Expiration: 10/3/2007
Type: DBA
COMFORTABLE LIVING CARPENTRY
JAMES WRIGHT
356 CHEBACCO RD. _,
HAMILTON,MA 01982 Administrator
EI`I P 1
PUBLIC PROPERTY
DEPARTI4IENT
KINGMUSY
MAYOR I20 WASMNGT N hMEEr S"LHK MAbSAd1l:5h1'R 01970
1t .979-745.959S•PAX.97&740.9er6
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.-
----
16y 1'j719r1 hOruu9'4
Property is located in a;Conservation Area YIN Historic District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land f >
Name: L
h GP G e r e /O� I a ro Q� i P S .L: G
Address:
d ev k/. z 07,q P rt h v.r.-t lw.� a /9 z
Telephone: ( I7 5`/�- / 3 -Z
3.0 COMPLETE THIS SECTION FOR WORK IN EXIS1lua BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of r�� I Area per floor (so Renovated
construction or renovation
of existing building New
&d Description of Proposed Work: yJj PcJ c� a h e;u /2 X/j
2 QI e ,<, Qck- / vr "�/ � (Q / � �
/ 3 X 2� P�v}Y �oo !^� / h (3hsP�•�Ph /�
Mail Permit to: U oX 4 0/i Z3 -- --
le 1&0
What is the current use of
the Building?
Material of Building? r ` O I"' �e if dwelling,how many units?
Will the Building Conform to Law? S Asbestos? & C
r
Arch'decfs Name
Address and Phone
Mechanids Name
Address and Phone
Construction Supervisors License# d � 3 Y Z HIC Registration#-Z= 2S z
Estimated Cost of Proj Permit Fee CftWtIon
Permit Fee i Il 001,a w Estimated Cost X$71$1000 Residential
- - --- _- -- Estimated Cost X S11/$1000 Commercial—
LLL�//
y o An Additional$6.00 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 lid to the abo a stated
specifications. Signed under penalty of perjury X
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