14 PICKMAN ST - BUILDING INSPECTION What is the current use of the Building? N dwelgng,how many units?_
Material of Building? U�Od —
Wig the Building Conform to law?
Asbestos?
Architect's Name
Address and Phone /
Mechanies Name
Address and Phone _ HIC Registration fl�—
Construction Supervisors License 0 _----
on
Estimated Cost of Prolect S o v Permit Fee Calar X$-jj
a o Estimated Cost 7131000 Residential
permit Fee S Es*-W Cost $"'$'0o8 Commercial
An Additional$5.00 is added as an
Administrathda charge.
Make sure that all fields are properly and legibly wMten to avoid delays in processing.
es do hereby apply for ted
.a Building permit
The undersigned
it to build to the above sta
specifications. Signed under penalty of perjury x
Date
e
1
9�
4'
V` N
s
Q
p O
)C6
Z
96 -
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
YMMERL EY DRISLOLL
MAYOR 120 WASMNOTON STRELr•SA EK VASSAOIUSETIS 01970
TEL 978-745-9595• FAx:978-740.98"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location \ L k
Home Owner Address `
Home Owner Telephone
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFIMTION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a fort acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and req r ents.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING IN
SPECTOR /f
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
snnaaav DMNC=
MAU*
120 W,msmcToe,s�rarrr.s�tita.M�arrso1970
TEL 9W45.9M .FAX 9W40.9t1N
Worlten' Compensation Iosttraaee Alsdav* BttildeWC8atnet0rWM4CMdam/p1nmbm
A
Names
Addres
Ciry/State/Zip: c• _ Phone
An you an 001111110740 Cheek the appropriate bast _
1.❑ I am a engloyer with 4. ❑ I am a postal eaouaeW sod I Type et project(nquiredk
employe"M and/or Pmbdme).* have hind the sub.�s d• ❑New conow [oe
2.❑ I on a sole pnvridw at parmee. HaNd on the aoaebed sheet t 7. ❑Remodeling
ship and haw no employees These ab.oaeuneclom have 8. ❑Demolition
working for me in my capacity. workma'comV•iantrsoce.
[�warkan'=:,ng
man S. ❑ Wean a eaepoeadaa red its 9' Building won
_,dequirad] oAicros have eaaniaed their 10.❑ElOMW repair or addidme
3. I am a homeo all work right of esmnption per MOL 11.13 Plumbing repain or addidom
myself:(No worker'comp, o. 132.41(41 end ere have no 12.0 Roof repaim
insurance requirefl t employees.[No waiters•
comp,insmamte requited.) 13. Other
150
t�wP�this seeds tea at son Wee Ad as ue Ueda.6elow ehoerlea their aades•
tCmaades �ben saw eaee�hed ad�d(tlaael hew d eeek erd dim hie oatabh emrt m6sit a sears seer ef�vit idleeda�emL rlarlee dr ed of ed deck aerhen•ea4 Pder iniaesetlo.
1 arse as arwployp that L provldGg workers' penwdoa !�sl taep/ayeaa Balow 4&a Jnjorwartlora pofkj a+rtJol.dri
Insurance Company Name: r �\
Policy Nor SaWins.Lic.
l�
Exptruion Date:
Job Site Address:
CitylStatelZip:
Attach a copy of the worker'compeasedon policy deelandea page(aka the
Failure to secure coven u � Poney number said s:PIntloa dab}
W required under Section 25A of MGL c. 152 can lead to the imposition of criminal pen Ides of a
fine up to S 1,500.00 and/or one-year imprisonmen4 as well as civil penalties inofuPtO the form of a STOP WORK ORDER and a Are
d 3250.00 a day against the violator. Be advised that a copy of this statettunt may be f tnves orwarded to the Office of
gations of the DIA for insurance covenga verill0tian
140/pnbp arri/y"djr dte peixt and penahim 0INdary that the/n joaaalloa providtl above it sew aw/eorred
Phone N: � N Cl
00cfd use onIA Do not write in IAb are4 to be completed by chp a lows oQfe/ai
City or Town
Permltll.►tease N
Issuing Authority(circhs one):
I. hoard of Health 1. Building Department 3.Cltylrow■Clerk 4. Electrical Inspector S.Plumbing Inspector
ti. Other
Contact Person
Phone N:
00;5
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MW;iKi.r.r )eisc011.
M."I ojl 120 W ASt11XGTON S MEET ♦SALPl1,M4ASS.1CI U.SL rl S J197C
TEL:978-745-9595 • FAY:978-7449846
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 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
1 11, S 150A.
The debris will be transported by:
—�— (name of hauler)
The debris will be disposed of in
(name offacility) \ \
C (address of farilt�)
signature pemlit applicant
(late
Jd;❑iL:f.LoC
1 1
PUBLIC PROPERTY
DEPARTI4IE►�JT
Kl1MCM N pRISCOLL
MAWN
130 WAS{11N(�y�51ub7 LL -MMUCHLSh1'IS 01970
717_974745-95"*FAX 978-740-960
APPLICATION FOR THE REPAIR, RENOVATION CONCTgUCTION
DEMOLITION 0R CHANGE OIR r OR � aZ � FOR ANY EXI3TING
STRUCI7m2 OR BULL_ —VG
--
1.0 SITE INFORMATION
Location Name
Property Address - -- -
//
Property is toeated in a;Conservation An►a YM Hlstorio District YIN
2.0OWNERSHIPINFORMATION S�
2.1 Owner of Land �(i Sr
Name: �o f5 C'�
Pci�Pcik % ;'O S-T
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISLNp BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use
New
Demolition
Existing
Approximate year of Area per floor(50 Renovated
Construction or renovation
of existing building New
grief Description of Proposed Work:
Mail Permit to: