66 ORNE ST - BUILDING INSPECTION (2) What is the current use of the Building? S�dc>r�hcn�
Material of Building? if dwelling,how many units?
Win the Building Conform to Law? yE S Asbestos?
Architect's Name
Address and Phone 1 y-
Mechanic's Name Or9ror+
Address and Phone r�c�C� Ye ✓t�3 1�/L ���Al3o,Y w� C7��fap
Construction Supervisors License# aS a R 3 q 56 HIC Registration#
Estimated Cost of Project$ cp oo Permit Fee Cftlatlon
Permit Fee$ �-� Estimated Cost X$7151000 Residential
-- - ---- - --- -- - - _ -- Estimated Cost X 3t1/i100O Commercial—
G 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 the above stated
specifications. Signed under penalty of perjury X
Da e �L Q
y N �
a
b
xt
a a a
EI`PY'-O;'SAIM --
PUBLIC PROPERTY
DEPART vMNT /� g
KuwF�r Duswu /l J // )
MAYOR 120 WAW N mn bmEET '
",^MAZACHLsmis 01970
TEL 978-745-95"•F=97&740.9g"
APPLICATION FOR THE REPAIR.RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILD
1.0 SITE INFORMATION
Location Name: Building:
Property ----
--- ------- - ----- - -- ---------
�CCO Qf ru Tern
Properly is located in a;Conservation Area Y/N N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: rd"F �
Address: Coco 0(-O Q S-}
JduAvv f A P, O1 O
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use N8w
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work:
�Q,�,O,cQY�4N�k of Qv�s�in5 k��-cl�ay� cobira��.
---- Mail Permit to: 1'-� 5A«,.� r�,4 d i,R>o --- --
CITY OF SALEM
� �' PUBLIC PROPRERTY
DEPARTMENT
t;,su;rn!.r.r ua!in:a.t.
120 W.\S11t\G"fON SCBEET #SA I F.M.k1ASiAC1 RSL11i 0197"
TEI:978-745`)595 ♦ FAx:978-74Cr9846
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
- -- (address of Iaiility)
--.. ._. sip azure of prnuit app ' a
62
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
awaEafa,t tatttcot�
tm vAuaNGmN s1' m a s umc m&%Ac Darn oiwo
Tit:97L745."" a Fax:9M709"
Workers' Compensation Insurance Affidavit BnllderelContnetorimeetric%=/Plamben
Aonlicant Information Please Print rAidbly
Name( orpsizatiowbwivi"): t Dais. -+T✓(9S / 7 J-, n u c.-r
Address:_
City/Stet MP: i�F.413a�% ry e7 of 20Phone#: Z2-d 6 5-9 3 9,,�2
An you an empioyert Cheek the appropriaw best
etpn]aet(regn4ed):
1.;9 I am a employer with 4. ❑ I am a general contractor and I � Q Nesv �
employes(tWl andtar part-time).• have hired the wbsooasdoes
2.0 I am a role proprietor or pamern listed on the attached sheet.t 7. ❑Remodeling
ship and have no amployeas These cob contractors have S. Q Demolition
worsting for me in any capacity. workers'comp,ioanance 9. Q Building atldltim
(No workers'comp.insurance S. Q We an a corporation and its
required] officers have exercised their 10•0 Electrical repairs air addit{ooa
3.Q I am a homeowner doing all work right of mtemption per MOL i 1.Q Plumbing repairs or additions
myself.(No workers'comp. a 152,41(4}and we have no 12.Q Roof repairs
ins u in"required.]t employees.[No workers' 13.Q Other
comp insurance require&]
'Any sPPOMM err.setts boa A mot-arse w out the seet{oa bdm shswisa reek wmksn'
t tiomaoweeo wee stdtnu this aAldsvlt commie/they M taiga s6 watt sad em hie a Wed a =0 ah■� 1 aaaawm a lWrW Wilkatlti sink.
rCaaeetlttien that shads this ban eetr sawhd as admdami ghat-Amin the mane of the and drain Wo 'aaoy.PWL7 blhm der..
Ian an employer that bproviding,workers'compensadon lnsaronee jof my rnsp/ayeea, Below/s the po&7 and job slag
lnjormado^
Insurance Company Name: 9.•i %d"t 66
Policy#or Self-ins.Lie.0 C3 ti/ `1Lf- Expiration Date
Job Site Address: & C-,:� C72 A-,* City/Stateizip:- S -e)� c"F.-, ^,a O.,g 7O
Attach a copy of the workdn'compensation policy declaradoa page(showing the policy number and aspiradom date}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to f 1,500.00 Indtor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
/do hereby ceratht ender flu ales aid"ojpe►j that the iA bfxmdon provided above Is&w and correct
Phone_#�
09"1 use only, De net write In this are;to be completed by city or town ojjfeial
City or Town: Permlt/I.leeme#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cily/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#'
I