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6C NIMITZ WAY - BUILDING INSPECTION ]w� ll �fnS What is the current use of the Building? Material of Building? if dwelling.how many units? Will the Building Conform to Law? y e,5 Asbestos? ° Arehited's Name Address and Phone Mechanic's Name �- [ �u rc Address and Phone I- > �— ConsbUcdon Supervisors License# ©I S 3 C� HIC Registration# Estimated Cost of Project S 00 D Pannk Fee Cal Won Permit Fee S� Estimated Cost X$7/$1000 Residential Estimated Cost X S41lS1000 Cornmercial- An Additional$5.00 is added as an Administrative charge. Make sure that all flelds are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penally of perjury X Qi2 V L per_ v Date 7 � � N YI � S, x a CITY OF SALEM PUBLIC PROPRERTY �� -O DEPARTMENT xnrea:nta,t txttscou, aI,►roa 1103rssemNcTMStaarr e sMatt,Meaaan:arnols7o M&9 6.74i9M a PAX 9711,740984 Workers' Compensation Insurance Affidavit: Builders/ContraetOnMeebicia»Aftinben ADDlkant Information Pie n.4..e s � Name(Bveiape/OrgaaisafloMndividual)' -- 20 b z. 6 J Address: %-.3 Ft czc Ciry/State/Zip:_ S v l e , i I`4 or 4p y Phone P_ 1�78- An you an employer?Cheek the appropriate host 1.❑ I am s employar with 4. ❑ I am a general oonteactor and I Type of Project( : 2.) employees(fiB and/or pa time).• have hired the stnbeonsarxors 6• ❑New conahucdon 4 I am a sole propdator or punier- listed on the attached shoat.t 7. ❑Remodeling ship and have no employees These have 8. ❑Demolition working for me is any capacity. works='roRMIN insurance. [No workers'camp.insuranee 3. ❑ we a=a corpora ois and its 9' ❑Building addition required.] ofllce=have exercised their 10.13 Elachicai repairs or additions 3.Q I am a homeowner doing all work right of exempdon per MOL 11.13 Phtmbing repair or additions Myself [No workers'comp• a 132,11(41 and we have no tnattranee required]t empl%em.[No workers' 12.[3 Roof repair comainatuaocerequired.] 13.�othar �n/G o l -Any aypa checks om er ches has el no also Iel as the seem Well,aewlea edrwakee• ttameowams who aemis dd$aMdaak maw esy son ddes atl walk s d ens lobe welds ae ®it aihmlt a ow eAldny lCoatrsetaae art cheek eb has amen aaached as add( and chant dwdoe en gams after waeomsams and their wakes•eamR lerbrmsues. /sae aw eeaployer that bprovlding,worker'eompensadoa lnsmraW*for my employees Befaw b tine lejormaslow, Padry and Job a+h Insurance Company Name 1A Policy M or Self-ins.Lie.M N//k Expiration Date: Job site Address:Attach a City/Swamp:City/Swamp:copy of the workers'compensation policy declaration page(showingthe potley number and axptratloe date)6 Failure to secure coverage as required under Section 25A of MGL o. 152 can lead to the fine up to S 1,300.00 and/or one-year imprisonment,as well as civil imposition Of criminal�of a of up to$250.00 a day against the violator. Be advised that a copP WORK ORDER y of u swcmem ru y be forof a warded Oflice of a fine Investigations of the DIA for insuraoee coverage verification l do hereby card milder the pains and pena1dm ojper/mry that the it l0fmadon proylded above is low and care Phone 6 2 OJJfekd mu only Do not wrfb 4 fhb area,to be completed by c4 of town oQkls, City or Tows: Permidjeense f Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City rows Clerk 4. Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone ll- o CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT numeRLry uRisccli \iat'CU: 130 WASI'IINGTON SCREET♦ SALEM,MASSACI-ICSL I-1'S 01970 Tr1:978-745-9595 ♦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 will be transported by: �arLL, s -,-'z Cw.� .�r (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signatwe o penult applicant date EITV-o" -- - PUBLIC PROPERTY '_, DEPARTbIF.�TT MAYOR 130 WA"NGr w SST •,E• .MAssntILst»sOt970 TIL•9"&74S-9S93 0 FNC M740.9W 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.---- _ - - - (o - I\5i� �, tt z i �7o 1�9A C3tS7C/ Property Is located In a;Conservation Area Y/N t!Hlatork 01aMct YM IV 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land L Name: L o u r s e, S F, C, r- Address: G- (? A)i m, � .S r,f e-, Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXIAZING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of �,y�� Area par fioor (sf) Renovated construction or renovation of existing building New arief Description of Proposed Work: I2 i^ r L ——--- ---Mail Permit to: _-- - -