121 NORTH ST - BUILDING INSPECTION EITY-OF&=, , Y
PUBLIC PROPERTY
DEPARTMENT
MAYOR 120 WAsancuxr N'IW 0 SntisM.MActAan:sE-1'rs 01970
TM-97&745-9S"•PAX.97&740.9"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 Nam: Building:
Property Address.---------- — — ---
Property is located in a;Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
4.1 Owner of Land
Name:
Address: ,/
Telephone: 'c _ 7
3.000MPLETE THIS SECTION FOR WORK IN FYICTING 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
Brief^^Description of Proposed Work: pZ
/ A A
�u
Mail Permit to Pesa 2 - -- -
What is the current use of the Building?
Material of Building? - If dwelling,ho many units?
Will the Building Conform to Law?
Asbestos? Aa
Architect's Name
Address and Phone
Mechanic's Name GO e
Address and Phone
Constriction Supervisors License# HIC Registration#
Estimated Cost of Project$ " 0 0 n Permit Fee Calculation
Permit Fee$ Estimated Cost X$71$1000 Residential
--- - - Estimated Cost $11/$1o0o Commercial— ----- - - -
�� An Additional $5.00 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 to build to ve stated
specifications. Signed under penalty of perjury X
4!!
Date
N
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w
I y
d 9
L, M
6 a '' 96
°°. CITY OF SALEM
PUBLIC PROPRERTY
/y DEPARTMENT
�17
\t-\1 oR ✓✓t✓✓J 120 WA.911NGTON STREET 0 SALUM.Al AslAci l.sl'1 110197E
Trl.:978-745`)595 • 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 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 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
-_ (n —,of facility) _
(a(dress o"f cility)
sivat e of pcnnit applicant
167T
dat<
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
aa.aan,taT tarn,00u
MAYOR
t201A406M"ftanT a SAtly,'dtuSAMUM01970
TEU 9787454M a FAX 97L740.9ft
Workers' Compenudon Imuraaa:e APNdavtt: BvllderslC0ntraot4r3M4C iidaaa/phm)M
A
Name 1 y 172
Address:
City/Statem;r mu M
An you an employer!Cheek the approprlab beat
1.Q I am s employer with 4. [31 am a Senegal Contractor rod I Typo et projen(r+ega "x
employees(!loll and/or pare-duse).e have hind the mtbeoanacaors 6' Q New construction,
2.Q I am a sole pifflFi ar a parmmto listed sat the awwbad sheet.t 7. ❑lsemodelini
ship and haw no employees Them have 8. Q Demolition
wort* far me in air Capacity. waken'comp,inwteeoa
[No workers'comp,mmraoce s. Q We area co7aratio n and its 9' Q lttaildiaa addhim
3.Q I Via dbo]mspw ner officers love exercised their 10.Q Electrical repairs a addielaos
myeeli ota workers' an work right of mtarption per MGL 11.Q Phtmbina tW�or adMoas
myseltifulusan ( �) comp. o. 132.11(41 and we have no 12.Q Roof repairs
t cmploveei[No waters' 13.❑Other
Campo mnnaoa required)
TA"WMm*A drab boa el mmt a m a am doaaetlea tadow ahswhy eri wmkma'aam ="do
lm s polef idsrtoa.
Remeowsma w 06mn Oia aeldwk Wk0ba dry am dais ar arrk Z mm his autails aekaama mad asbark a aw afadwk
rCaaaeeeom tlr<daek Ili ha moatli aehad r addltlaad sham abowiee de soon afar aahsaeaaerm ad drk umbra'asap ibnaatlaa
,ran an ewployef that bprovldlmt workers'compo ux6a buareacefor MY e ees Be
lafonmadota apby low b dYe poBry aadJai dh
Insurance Company Name:
Policy N or Self-ins.Lie M
F.sPiretion,Data:
Job Site Addrpe
City/stawzip
Attach a copy of'be warkesti'rompesaadon Policy deebuarlon,pap(sho the
Failure to secure covers ar � Pommy number and e:ptratton,date}
fine up m"cute CO and/or s mppl[ed under Section 23A of MGL a. 132 can lead m the imposition,of criminal paoalt�ohs
of up to 3230.00 a a Y tm o ' e we "civil pewitia is the form of a STOP WORK ORDER and a Fw
day Sainst the violator. Ht advised that a copy of this statement may be forwarded to the Otltce of
Investigations of the DIA for insurance covenp vesi}icadon
l do hereby cardA under the pah"and pemaNa ofper/ary that the In
/otmakm provided above Is Ora and comes
Phone
0A1W We oxIA Do mot write in this arse,to be cosplew by effp of town oQfctoL
City or Town,: Permlt/Lleesu N
Issuing Authority(circle one):
1. Board of Health I Building Department 3.City/fown Clerk 4. Eleetdcal Inspector S.Plumbing Inspector
6. Other
Conhet Person:
Phone#