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23 MASON ST - BUILDING INSPECTION PUBLIC PROPERTY ,I DEPARTMENT KINwFxsrouscou N.�roa '1 NNN 130 WwuNG"b rawr 9 '"MEK Mncsna4t:sc-rts 01970 M-971474S-9S9S#FAX:97&740-98" 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 MAS01V Si sALEM MA cX970 Properly is located in a: Conservation Area Y/N Historic Dishkt Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: P— 3 EN /, o Address: 93 MA-soN 67- s,�t�-M MA ©i97o Telephone: 617 3 62/ 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing 7 Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation ��g0 of existing building New grief Descri�on of Pr osed Work: �/ ) wo � �eeQ/ E Mail Permit to: -- What is the current use of the Building? Material of Building? (J 6 07 — If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name — Address and Phone Construction Supervisors License HIC Registration# �— Estimated Cost of Project i� Permit Fee Calculation Permit Fee$ Estimated CostIS1000 Residential -------- — Estimated-Cost X S11/$1006Commercial-- An Additlon I $5. 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 Permit to build to the above stated 01 specifications. Signed under penalty of perjury Date o vl H K x � . aN � � a I� CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT rn+aottttt rrmr.v. Nntraa 120 WtvvmactcuSttttaT•Stu.ot,llwsti►Cal>zrtS01970 Tau 9W43-IM a Pa74 9w40.9Md Warners' Compeuadaa Iunrmo Att)davit: Bnitdawcontrae Anntteant Iet sdon / Pl /tl Mnt*oodbly NameiDGn � City/St"d0z*- L,0, s _ rr�f} P(lone 7e-45 7'V17f9oel-iQ— Are you as asplayar?Chat do appropriate beta 1.❑ Ism a employs with 4, [31 an a metal oammece r and I Type of project(roqMv* employees(IhB amdtar powim )-o have hived the L New conduction 2.10 1 am a Sala I Mpeiaoor or partner. listed on the ausehod sheaf,t 7. .911lamodelims ship and have no employees Those ab•000tractoes have L ❑Demolidan world" for me Is aW capwky. workers'comp,immanca (No wahara'camp,inaraws !. ❑ WG am a corporation and its 1C O Building addhims R I 3.❑ I �hm)meowns o�cera hove srarcieed reds rapdn or addition dofiy so work right of aaeeption ps MfB. 11.0 Phombing repairs or addidow mysex(No workers'Camp a. 132.I1(4).and we have no 12.13 imea nce )t employees.Oft wad=** Roafrepam cOM 13.�Other p,ioanama required) �tia Wilma sr atla teen®rrr.ao am do aria eru.ra.ydtrrwakl Hoes s"WIS Ma Slob rids dedmva bd 01611 dry N doing as amdt d do fdw adds ri gait wlsrlt sew alRd ri tCorrmelors dfn dmati this to cot asthma r add d d sh"slowing wing a s mans ardw si.omnaoima d 6i robe-coup that Iryrwdr V worRrrd'n t'"slOn Jk Soy aa'Pfeysaa Bsbw b tAs po/!ej mrlJod sblr Insurance Company Name: Policy a or Sal[lees.Lie. &pirsdm Date:-_ 06-2 x— ZooB Jab Site A AeM CuyJSyte/Lip !�/9 Attach a copy of th*workers'eomPaasa&n poiley declaration pap(shoring the policy camber Sad uplrayoa dated Failure to wean Caversp as requited under good=25A of Ma a. 132 can lead me the nopaeitiaa of crinebw pews"ofa fine up to51,300.00 arils one-Yes impriaoumem,u wall ascivil penalties is tees fam ofa STOP WORK ORDER sad a Ace of up to S230.00 a day against the violonor. as advised that s cc"of this statement may be fatworded to the 081t»of Investigations of the DIA for insurance coverap vau ados f do barrby caal�y awI oJPadwJ'rhar tbs la/orsrado�s prv(dd abon 4 arw od tamest i Phone_0 O;rid Cars owlp Do war resits ba Ab arq,to be compkhW by rby or town ohk&L City or Town. Permillucase d Issuing Authority(circle one): 1. Board of Health I.Building Department 3.Ciry/rows Clerk 4.Electrical Inspector S.Plumbing Inspector &Other Contact Person Phone N s!Q/AO�'L'�7�'M�MM f0'9Z-S Pas�n� 6tU-LU-LI9#n3 myss Watt m 9W Vm 006ti-LU119# 101 MEOW�fl nopgam"m P"Wo q=P.Wv P=. wqP gtamq ssy�3o gRw&°oumwD K =qm•mg Pm vuogds!sn'"'PP••.m°°a'•d'Q oql 00 aa!*aq sM dP*midmy s sn*Ad Am snsq nod VjnmF Pm aoDsrsdoo�mod naenp•IS!nod�losq�a al!i Phan`saopdW* P"Wo vu 'sao!uonb W SPAR amq a Pmmd so MMM SW s rod) Pm nn�Pr.�e AM v Mmm so wood•w41 m%919 ao 91 vopw 'gpgp MP)o Ado*V«[wno3 a pgnnwd aq Awn amm so AM aw Aq My m�°p��{/dA•!'iH°O°oq Mq 3!)�P•mso}m A*"od so Avor�o!somm" i 0•:.a13M1.p!nogs M•oflddC aw r--�r_ a!S f."R �•1m( m�sq� 1u*P�•aso A M Paas'mad OVAd Am m s�Aaalldd' as ssea p asgld WOO =,aupw al mq=o s M peon aq . 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