1D NIMITZ WAY - BUILDING INSPECTION What is the current use of the Building? M dwelUng,how many units?�-
Material of Building? �°� � Asbestos? N �•� `� .
Will the Building Conform to Law?
N
Architeds Name N
Address and Phone
Meehenkds Name S I� ..,
Address and Photo i- � 1--�c-L �``- c
ddre s and hone �aots UCenSe OI?3—y` HIC RegistrationConst M
tion
Estimated Cost of projsd S P Fee Caksulatfon
Estimated Coat X S7IS1000 Residential
Permit Fee S�
_ .-- - - Estimated Cost S"'$'OW Commarc►at An Additional$5.00 Is added as an
Administrative charge.
Make sure that all fields are properly and Iegibly written to avoid delays in processing.
The undersigned does hereby apply for a Building permit to build to the above stated
speCifl Atfons. signed under penalty of Psdury
Date62
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�d- O CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MAYOR
120 WAgOlf.rQMSntsar•SALEK MANACMIMM01970
Workers' Compensation Insurance Affidavit: 8aditWC4ntracto
Annikant Informationtie* tw
Name Address: !- r� 1-4 cxA 4 /.
Ciry/StatelZip: S� ��„ r7/� �l���Phone N 5 7 S-5-)8- <A/e, z
Are you as emph►yart Cheek the appeoprfW bass
I.❑ I am a employer witY 4. 1 am a Semaral cosmadcr and I Type of Prr1eft&MqNkeo
empioyeas("andtar part-time}' have bi vd the sub coopacoots 6' ❑�'construction2. 1 am "prproprietor or patmen Hated on the aaaebed sheet.t 7. ❑Remodeling
working for ma in any capacity. workam,comp insmance. g• ❑Demolition
[No workers'comp.imomnce 5. ❑ We an a carparadon and its 9. 13 Mulding aka°
ie4uizat] OMCM have a malsed their 10•❑Electrical repairs of sddkiom
3.[31 am a bomaownw doing an work light otaeamption per MOL 11.Q Plumbing repairs or additimm
myself(No workara'comp, a 152.41(41,and we have no 12.p Roof tepaiea uuauaoee 1 t Campionua MPIGYNL n re"ind.) 13.[�Otber l�z�,l oc� cl e c,L
;Ar atgaom Wt ahadu ban 01 moat an rm on Ma"Was Lwow Ambg Male aerkmr•eaaasaaaulaa 7dkr ta6rsatlae,
Haemoem*roe k Ms Mi m am indenting May am dais d ere*aa/!m tdm swig�Pout atdPoit a area atedaab
tCmuaetaaa Mat eaaek ills bear Pow aearad Po sdowd atom Moeise Mrsear a/Ma aa►aoauatram red Male aaa a me,
lase am employer thae bprov/d/aj wertera'compemaedom Gtsrratcojog my e
tmjormtadoat apbyaa Bdow b rho poifry aauflal dle
Insurance Company Name:
Policy M or Self-ins.Lie.tY NIA Expiration Date:_ N//k
Job Site Address;_
Ciry/State/Zip; AJIA
Attach a copy of the workers'compewtba podey deelarados page(showing the
Failure to secure covenSection
a imp number sad expiration date}
rule up to 31.500.00 and/or one under See nk 25A of MGL a 152 can lead to the of a STOP of criminal penalties of s
of up to 32S0.00 a der a y viol&W.B advised
err wen as copy
penalties a the form of a STOP WORK ORDER and a fine
Y you for ante or. ra advised that a copy of this satemem may be forwarded to the Offtc of
lnvestigadont of the DG for insurance coverage verification
l do hereby treat under tlto paGv and pema/d"ojper/mry that the!n/waradow pro vtds!above b sera and eorred
Phone
Weis(use oast Do not WHO In A10 area,to be eompbeed by city or town olJ$lal
City or Town: PermittLieense N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. ye Clerk 4. Electrical Inspector 5.Plumbing Inspector
b. Other
Contact Person:
Phone p•
CITY OF SALEM
ow&
PUBLIC PROPRERTY
DEPARTMENT
120 WASHIXG"rON SCREET•SALVM,N1ASi.%CHL.iL1-I'S 0197C
Crt:978-745-9595 ♦ F.{r:978-74C-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR 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:
Nru ks <- Cam...i ,Vr
(name of hauler) T
The debris will be disposed of in
(name of facility)
- ----- nulurcss of facility)
PUBLIC PROPERTY
DEPARIT,�,�T
1IAY0.
130 WA"mGj[kl.fin T•Smak VAsaeas:s *M 01970
T L•97L74&959S•FAX 97L740.98 {
APPLICATION FOR M REPAIR. RENOVA1ftON CONSTRUCTION
DEMOLITION, CHANG9 O OR
STRUCTCrn FOR Vast
OR BUILDnv�
1.0 SITE INFORMATION
Location Name:Prol Building;
Address:-- / - ._N i f z ( �Jo y
Property is located in a:Conservation Area YIN �/ Historic Dbbict YM
KOWRW
HIP INFORMATION
LandE al� z 14- e r-
1 - DelfCoe;/
3.0 COMPLETE THIS SECTION FOR WORK IN EXISLNQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition
Existing
Approximate year of Area per Floor(50 Renovated
construction or renovation
Of existing building New
9de1 Description of Proposed Work:
1\ e-0 '0 Ce_ �IS L 1-,e• LJe e
-- -- — Mail Permit lo: 1 -- IN) k fz