15 PATTON RD - BUILDING INSPECTION use d the 9uildinp?i
vVt+at is the current c. M dOhow many units?
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pAatufal of tjuildk+p? ? �
to law?
L S _ Asbestos
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Contbrrn
ArchiOacCs NaM t
Address and hhww
Medhu►k's
Name
Address and Plwne isars Ucense a HIC ROGWOWn 0 ILE
Canatructlon SuPary
Estln+ated Coat at ProJed
/' D� Pemilt�,Fe!Cam
• Estln+atsd Cat X i7/i1000 ResiderMlal
Pemt Fee
Estlrn.oad
Cod x ii tril000 commerr l-
An Adownsi$5.00 is added ae an
Admk ktathre drupe.
Make sure that aN fleida are PrOParb and Idobti written to avoid"my*in proeesain0.
The under Wwd does heraby appiy fbr a 8ulidkq buUd lam
sue, 3lpned under penally of PwJurl `
Date
/off
F VZ
s.— OIL—
PUBLIC PROPERTY
DEPARTI,MNT
NAME 17101•eaanel�+n yn�• �✓//
�x�1C1Lf1gli 01Y10
11a:f?L7islSq�RAs 17a.7�9eM
APPLICATION FOR M REP nz RtNOVATION ONSTR[TCTION .
DEr[OLITION.OR CHANGt OF USt OR OCCCmtLNry FOR •,wIVA�STIIITT,
MMUCTM OR BLm-nt Q—
. �.o mE lNFowwAno •• -
Location Names /F .
PropertyAdotresa: 1 � �.
Properly is IoeabO in a:Corwrvatlon Arne YM HNlorb UbMa YM 27
20 OWNERSHIP INFORIIIATION
9.1OwneratLOW
Ate....
Telephone:
3.0tOMPLETE THIS SECTION FOR WORK IN RKTING BUILDINGS ONLY
Addition Existing
Renovation Number of stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per Boor(sq Renovated
CO
nstruction or renovation
of existing building New
Wd Description of Proposed Work:
Mail Permit to:
4 CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
EI\In KLEY!�IUTA 11.
\t.U'lR 110 WAS1111"Gi0NS.REET •SALIA1,MMiACi LL.SL'1 IS':!WC
TF.t.:978.7454595 •F.--x:978.74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 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
l 11, S 1.50A.
The debris will be transportte`d'by: Lam'
(name oEhauler)
The debris will be disposed of in
(name of facility) I
I
of facilay) _ .
V i:aturc of pern,it:,pp,ivat ----
.:aLe
.� C S
TTY OF ALEM
PUBLIC PROPRERTY
DEPARTMENT
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Ta@ 99W454=.PAM roar its tut
wwbW GampewdGu Iss.n,e.Al WaftAnnfift
gip
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Are yea an.mplgor?Cbmk the.PP►ol bent
saondaebeeffraadI
1.❑ I®.. % "ow www peFdmep a bm hked tie wu.�
oosba don
2./Q I=s nb pap,a profs. rimed an tb aaww theft td,Wg
ship and have se anpbymm These
working ON me in coy aepeet y. w dwat' iaw iitle.
(xo wadrow corps manseoe l• ❑ we=a atpmMnn and ita�ache"have exmdoed theireal„pair,or addidoae
3.❑ 1 mahomeoww doing an waft dgbtofnamptianpmMB. t rlrW a addbYous
issuance ''comp a plo a E a9d Ge haw sspa m rrPbyat Qfe waekaM'coop ifeaeaon A4'4efe.r efte�ede Ica d...e.l..
Y �
tc..r.r.e dtr d1�b afa het gar Yrbed r edrdr/dlsst+wre i�s.ti °'+"11e r.d.t..w elpt,.b 6lhtdy mi
lam aAaypby r aiaf b �e0rr�rl dti wadeef'eaap t�
lafirwatissM l warners'nw0auednwt bsatnaseo�r wl aaytoyaa daieMr b tMePodr)aa/fad ady
ineuaoee Company Name:
Policy N Or Wins,LIL b
F.apitatlan Date:
lob Site AAdrew --
Attach a ceq of the worl compensation Doge)'deehurat4a �
Failuew to secure eovaea a paM(rbe"the po ft Member and"piratbn dW).
P re PkW tinder Seedon 23A of UM e. 132 as lad to the imposition otaio
Hon up m sill"war oowyear impdsasme t.U won a Civil Dwidoo is the ram oh STOP WORK onD�s�ad�ffae
of up a f2lo.o0 a day apiast the viotatar. Be advised that a copy of thin=Umax mey f Or71a ail
Investigations of the DIA for kwaeee covmp veitiatioa be onuarded to
the
/Je harrlp palMe aMlOrwou4r 0011 7 dw At 11V owdoloe
aavud abera b aw/earraet
1 8
OQielat eta oMl jt 00 Mat wr*In u1b arm At be comphta bl cup Or m m sAAW
city or T.wr Permltll Itew t)
Isruing Authority(circle ons)s
1. Board of Health L Building Depsrtmeat 3.City town Clerk 4. E& Other lectrical Inspector S Plumbing [mpeetor
Contact Prima: