50 OSGOOD ST - BUILDING INSPECTION .r
What is the current use of the Building?
Material of Building? It dwelling.how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone t )
/i r fVrf
MachanicsName -� ��'�
Address and Phone�� e � ti G v
Construction Supervisors License# CJ 7 1Z ?7 HIC Registration#
Estimated C of Project S �i 60-- Permit Fee Calculation
permit Fee i d�� Estimated Cost X$71311000 Residential
Estimated Cost X$11/$100o Commercial-
---------- -
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fleids are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the a e stated
specifications. Signed under penally of perjury /�
Date o
el
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--
PUBLIC,PROPERTY
\' DEPr1RTbIF.NT
wLwffinlilt DRl%COIl �o�
NAVOt 130 WASXINMW 5nF8r•
•.emu MASSAOII:Shl1501970
IVL-9 a-7ii95"•Fa¢978.740.9W
APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
[FPropertyAddre
.0 SITE INFORMATION
ocation Name: / f Building:
A
— - - `—�
Property is located in a;Conservation Arse YIN Historlo District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: �v! S o C-�
Address:
Sa
Telephone: � / �- O — S �
3.0 COMPLETE THIS SECTION FOR WORK IN E7(tSLN3 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Srief Description of Proposed Work:
- 5
7 /77
Mail Permit to: rt--7 ce-Ic'Ci Y -
I
� J'tur tirmwronaveandtdu ojl'TuZ`aasgaac9neaseta& ( e;}���."s
l r-- �_, d)ellaerttlecaat .,",,",.ade4striaadtflcciaderats ,
Of of Itaveste�,rtiolas LICENSE # ----- - —
600 4";cishington.street DATE
Boston, MA 02111 - --
Ivlvw.M ass.gov/dira
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): t,)11, r C// Gcle
Address: �—
City/State/Zip: �/���vn /1'//f Phone#: _2
Are you anemployer'.( Check the appropriate box: Type of project(required):
L l�am a employer with ` 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-(ime).* have(tired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. # ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
worsting for me in any capacity. workers' comp. insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their- 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]1 employees. [No workers' 131-]Other
comp.insurance required.]
*Any applicant that checks box All must also fill out the section below showing their workers'compensation policy informffiion.
t Homeowners who submit this affidavit indicating they are doing all watt and then hie outside contractors must submit a new affidavit indicating such.
1Contractm then check this box must started an additional sheet showing the name of the sub-contractors and thew workers'comp.policy information.
I am an employer that is proviAW workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Comp ury Name: — Cr
Policy#or Self-ins.Lic.#: )5" X,.,6_E-'V) Expiration Date:
Job Site Address: ew�3`li vocl5 - City/StatdZip:
Attach a copy of the workers'compensation policy declaratimt page(showing the policy number and expiration 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$1,500.00 and/or one-year imprisonmerC as well as civil penalties in the form of a STOP WORK ORDER and a fine
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
I do hereby catyy under the paurs an of perjury that the information provided above' true correcit
Signature � 7 f: M ,e Date:
Phone#:
Offuaal use only. Do not write in this area,to be completed by city or town ofyicial
CITY OF BEVERLY 978.921.6024 PERMIT
OFFICE OF CITY ELECTRICIAN Telephone
191 Cabot Street 978.92Z2548
Beverly,Massachusetts 01915 Facsimile INITIAL
if i/Iiam Ambrefe 978.921.60M 978-423.7468
Inspecror or Wires rnnncbever ma. v Cdh'Ivr
13' 180-43-5864 7 DATE
cityelecttician@beverlyrnagos, Direr
• CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
IIc w.\:tIN':a\:s.1Ecr•SAL.".
Ttt:VM7+3.95" •F- 976-740.9M
Construction Debris Disposat Affidavit
(required for all demolition alxl renovation work)
In accordance w ith the sixth edition of the State:Buildings Co(* 780 Cb1R section t 11.3
Debris, and the provisions of MtGL c 40. S 54;
Building{ Permit 0 _ _ is issued with the condition that the debris resultin1 ftom
di this work shall be sposed of in a properly licensed waste disposal facility as defined by .1GL c
111. S 130A.
The debris will be transported by:
(nar a of hauler)
The debris will be disposed of in :
(numr ut la:ilny)-
♦._:..�f�::ql MAC J:a.K1de
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