0020 PLEASANT STREET - BPA-07-982 HALF BATH What is the current use of the Building? units?
Material of Building? ' j-y��— If dwelling,how many
Asbestos?
VVfN OwBuildingConform to Law?
Architeds Name
Address and Photo
Mechanic's Name G� �'�` / s h A—
Address and Phone B �/3 HIC Registration 0
Conduction supervisors License ti
Estimated Cost of Project S Permit FN Calwlallon
�:� Estimated Cost X i71S1000 Residential
Permit Fee: —� Estmated Cost x s111i1oOO Camme►cia4-- -
_._
An Additional$5.oO is added as an
Administrable charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
hereby apply .a Building
�P/artnR ui to the
The undersigned does s led
specftatlons. Signed under penalty of perjury /� T
ate 5 e5p
N
PUBLIC PROPERTY
DEPARKINSFALCYORWAXL
TIVIE,yT
MAWR
14 WAvur -"*IrIEU•UWEK yAMACHLSkTM 01970
TEL 9- 7ii95"•FAX 978-740.9Nt
APPLICATION FOR TAE REPAIR RENOVATION CONc�UCTION
DEMOLITION. OR CAANGE OF US* OR c�rma,n►CY FOR ANY EXISTING
STRUCTCRp OR BUILnrntr�
1.0 SITE INFORMATION
Location Name: U 2i i Building;
Property
Address -- --
Ali E
V -
P►av«b is bested In a:Conservation Are@ YIN Hlstarlo District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: z
Address: �J
C� -D !/ �e ;,z
Telephone: (7/
3.0 COMPLETE THIS SECTION FOR WORK IN MATING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use
New
Demolition
Existing
Approximate year of Area per floors
construction or renovation I Renovated
of existing building i New
Bcid Description of proposed Work:
G
Mail Permit to: - -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
AV
traaaeatatt ywrev,
Ttas 971.74s939s.Fsrr:97i71O9etL
Worken' Compeaeadon Inearann AflltiavW Bofldem
Anof natInb- afte
pi"tt+.t,.►9.elves.
Name 6�
City/S Phone N:___ 9 7.f —F 02_j /,J
Are ym as amployert Cheek the appropriate bast
1.❑ I am a ensployw wick 4. ❑ I am a pmetal eamtsetor and i ��]�
see(tWl anther part-time).• have hired the eubcoauaceom d" �
2.U'"am a sole peopri, a or pansies• lieeed on the load"them.1 7.
ship and have no employees has tnboomsoeas haw !I. ❑DmwHdaa
working tar me he say capacity. workaa'Comp:i ksuvw&
(No wOrkms'Comp.iaaaaap S. ❑ we am a caepmadea and is 9. [3 HuMn addkima
requited] o8lcom hew=Kcfsod their 10.13 MOcticai mpeim at additions
3.01 am a homeowner doing ill work risks of eamn "Per MGL 11.13 Plumbiei repel at additions
myseit(No workme'Comp. c. 132,41(41 and we have no 12.0 Rodmpdm
10nmd1 t emPloyaa,Pb workers' 13.13 Other
�bauson required.]
?*M'"ploW entraedat ben at me dr at ae de rstlr trloto rlrMq erlrwakaP
L ----------i
Homeow who Admit*A law"mdrWa day wodulyds�akrrereamlltaaraates.�i�.evedaduae
rCaaeeeaoro er 3aek db Met-mat isaaed r ddard drr Ambg er rear ofdoan an AwPkYw ai.eoonenm r entr earf>s•oe4, tathr�tloa.
Inf that Is previdlws wor,Yen'ceaeoeatedee iarrn+ac.Jbr my'PAWew Bdar b rAe peftry aw/Jo1 r!M
Insurance company
Policy M Or Self-ins Lic.Air Eapindoa Datr
lob Site Addreae �J�iArAv �� Cihigtsoellip � iyi t��J�j
Attack a copy of the workers'compeamadoa pogey duelaratles pap(showing the Polley number and
asptratloa data}
Failure to secure coverage a required under g�23A O(MGL a 132 Can lead m the impoeirien of criaoisal fine up to i 0.00a city
and/or one year imprieonmeaR to won a civil MWdes in the form of a STOP WORK ORDER and of Aar
of up to 5230.00 a day against the violator Be advised that a copy of this statement may be forwarded to the OtWw of
Investigations of the DIA for insurance coverap veriAatiOL
I do hereby co dar uy
L an/Pe olaedwy 1AM nee ivfwxedeeororided above 4 a"
211
O0?cid rise oeilt Do not write in tAk ere.i to lot completed by cAy or town o.Okki
City or Town: Permit/ ictae M
Issuing Authority(circle ose):
1. Board of Health L Building Department 3.Cityfrow■Clerk a. Electrical Impeetor 3.Plumbing Inspector
k Other
Contact Person:
Phone f:___.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 WAiHING ONSMEET♦SALIAi.MASSACn.SL17�Qi97C
Trt:978-74 9595 • f.jX:978-74C-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
I It, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of fLcilt_) �����
siguatura ut p rtnit ap icant
date — —