60-62 PERKINS ST - BUILDING INSPECTION What is the Current use of the Building? IN dwelling.ho ma ny un'As? --
Material of Building? Asbestos? � ()
WAN the Building Conte Law?
Architect's Narne ( 1
Address and Phone t
Mechanic's Name R Sp ueA
Address and Phone �Yss�6 HIC Registration N 0601
conetnx Non SupervL License _ __----
Estimated Cost of Project S N — Par n
Estimated Fee Camated Costd X$71$1000 Residential
Permit Fee i —
Estimated Cost 11111s1000 _____
An Additional 95•oo is added as an
Administrative charge•
Make sure that all fields are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building permit to build to the above stated
Signed under penalty of perjury
Specificauone. g
Date
I
S
a
p• •s � e G7 > � 3
EI'1'X OFFg � -
PUBLIC PROPERTY
DEPART NIEINT
130 Wwurw-uw bruer. k- /
WssnagL5 s 01970
7%L MTMS"0 FAX 976-740.U*
APPLICATION FOR THE REPAIR. RENOVATIAN CONSTRUCTI N
DEMOLITION. OR CHANGE OF USE OR OC mwcy FOR ANY EXISTING
MUCTUIK OR BUILDiN
1.0 SITE INFORMATION
Location Name: 6d -6Z Perkl)q 5-r �6 QW 9uildWS
Propeny Address bo-lz @& n3 -7- 45G Q�
Property Is located In a;Conswvadon Area YIN Historic Dlefts YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: E�J /e✓� In$ �p _R U ST
Address: �� 1R�Z�zyj Q
e ,j
Telephone: °�1� %SZ N�
3.0 COMPLETE THIS SECTION FOR WORK IN ",SANG BUILDINGS ONLY
Addition Existing 3
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing b s C7
Approximate year of Q Area per floor(so Renovated
construction or renovation I I
of existing building New
Sdd Description of Proposed Work: Vl h 51 ex 15� i vls ��0
n �
q ,Q"0Uc � Replace Z sec`s 6f
-------- -------
Mail Permit to:
CITY OF SALEM
,i PUBLIC PROPRERTY
DEPARTMENT
XI4I:hM1LEI"1'nl)i;lH 1.
\1.',Yt�I: LO\%�.\il IINt,CON STRflET�SdLL\1, fit.\tii.\CHI.tiL rl�0197J
TEI:978-743--9595 ♦Fax:979-740-9846
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:
—.._.._ f hauler)
fhe debris will be disposed of in
Sam
(name of facility)
i o gaJod_V Wlp1 m
I udd ess of taal¢yl
By
CL
cl-,at
? wc ut �nrn�it appiicant
.ate
CITY OF SALEM
PUBLIC PROPRERTY��
DEPARTMENT
a'.DI.aldllt oascota.
can nee 1M VAa@U.M ftMff a&MJX MAUACWWM 0lW0
TAs 9W45919!9 FAx 9W4a9W
Worksno Compaasadon Insurance Affidavits 9WdmXa
ADodcant Intermadee er print r
Naatte( '
Addt'as: '
Cit3/3tsttt/Zip Phone
Are yore o ampMyar7 Cheek the appropriate heal
1.p I as s employer with 4. p I an a gene eaattaaor and I
employees(fall and/er put-dme).a haw hued the L p New cosenwaine
2.0 I aaa a solo peoprlotae at psamea listed as the attached abseL t 7. ❑Remodeling
ship and haw so employes Than ad000uecmn have L p DemoHd=
Working for me in saw capacity. wmtltets'CON96 ineutastee g, ❑gym addidas
(No wadras camp insimm" 1. p We am a cotpoatian and id
3.01 y y� oateaes have e:mciwd their 10.p EleeWAd NpWas or addtdaas
doing all work risk of eeamption per MOL l l.p Pbsmbiog mpaits or additions
mywlt(No wa it= comp. a. 112,41(41 and we have so 12.13 Roof tepaim
10roroes teghoted)t employees.D b wotkseea' 13.p Debar
�taaaaow 1
-tie wftw Rat dmb tax at mw do ea am do me"bdowalwly dixadam'aaa'mtrlax
Bamasraaw�ara.imnur.mdawmdlemiasa"amddaarwdtad60himemrba.xaap�e�t�riaraatoeaaa
tCaasuama art dmk dY bee mom iaaead m add dmd dmt dacha dr.a afda aobeaaramom seed oar wabxp aaq,assay hdMM ds
ow eaaptoya tAae frpret tag workers'eowpenradea buwawe for my employees. Re
Ar tAeangry rmd fo1 sEAs
ferwacloaa
Inaum"d Company Name:
Policy N or Self-ins.Lic.N Expirsdoe Date:
lob Site Add'ew City/SOte/Zip
Attach a eopy of the workers'compaaaadot policy dwJws ea page(showing the potty another sad ap iragoa deep)6
Failure m sccum coverage as reputed under Section 21A of MGL c. 112 can lead a dw imposition of aimisei penalties of a
Am up to f 1.500.00 and/or use-Ycw WWUonmeat,as well as civil pensitiee in the fotm of a STOP WORK ORDER and a Asa
of up to$250.00 a day against the violator. Be advised that a copy of"aatemeat may be forwarded to the Oulu of
Investigations of the DIA for insurance covemp vaviAeuion
I do hereby rardh ands AepW"and peea/der ofP*?J&7 dw At/nforaredow provided oboes Is a w and comet;
34mature.
Da
Phone N:
O,QTeId wee only► 0e nod wdb!a I t arM to be completed by dip or low o4k&L
City or Tows: Per=IUUotsse N
Issuing Authority(circle one):
1. Board of Health L Building Department 3.Cityrrown Clerk 4. Electrical Inspector 1.Plumbing Inspector
6.Other
Contact Person: Phone N