23 PROCTOR ST - BUILDING INSPECTION i
EItAVOF --
�fJ / fl
PUBLIC PROPERTY
DEPARTMEINT
/:1\mcn cv DRISCIHl. /
UAYOt 130 W"arAGww S'rREET "LaK X.uUctft;terls 01970
TEL,r$-74S-9S"*FAX 976740-95"
APPLICATION FOR THE REPAIR.RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
11.0 SITE INFORMATION
Location Name: Building:
-- -Property-Address:— --- -- —--
2,`-� PRGCraR 9J .7,4Z5;.� IWSS O/920
Properly Is located in a:Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
1
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXiSMI .CiSMIXG BUILDINGS ONLY
Addition Existing
Renovation P-01� Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Hciet Description of Proposed Work:
A4i-1-7✓r g4145- Ago �:GatrG r%✓ /�/z�^r i"
Mail Permit to:
J
1_
what is the current use of the Building?
Material of Building? h Z*O If dwelling,how many units?
Will the Building Conform to Law? le, Asbestos? /N d
Architect's Name J 09-pG •Wrl
Zf- S�3 2 7
Address and Phone
Mechanic's Name �05/
3 Z
Address and Phone 2 2 P/t �
52
Construction Supervisors License# 0 6 �y Z HIC Registration# l 212 L
Estimated Costproec Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
— - --------- Estimated Cost $41/$1000
An Additional $5.00 is added as an --
/05 Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
& 2
N
30
0
F o f� C7 y y
4 u � a -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
amtmutlt tanoou
atn,raa 1I0 VA90 . W S==0 SJWtK MAitACAMM 01970
TILs 9W4&"O$a FAX 9W40.9edd
Workm' Compouadon Imarsaat AtIIdavib BadeWContraeftnmiftbidaufflbers
Ann&ant Inhrmadoa
PM " yt,.e r.raver..
Name t :
Addraa:— 2 Z
CitwSteterz;p: 5� s _ Phonew- 271'-62/—V32- 7 -
Are you On am~Cheek the appropriate boat 'type etpra feet
1.❑ I�a amployer with 4. (31 am a pmetal oaaaader and I
(khB and/or pert-timed a have bated the n bcont acen e S �Con
2. I am a eoD proprietor or parmeo- Bared as the attached rhea,i 7. Ra♦odetlag
ship and have no employaw These sudnmaetcae haw t. [3 DsmoEdm
working for me In arty capacity. workers'Comp iostaana�
[No rrorlran'comp inateanee 3. We an a Corporation and its A ❑ t addidm
3.(] Ing am a bo homeowner oAkeme haw wuncised their 10.0 Electrical repain a addidaee
a om doing an work right of a samption per MM 11.Q Pig�or addtdow
MYUcomp, o. 112,41(4)6 and we have no 12.0 Roof
repain
Wa mmn required.]f employees.[No workwa' 13.❑Other camp'insurance eegtdeed)
tiT urn.lobeanmoswasaarassec"bro.re.ydair.ot�' .
Haereeawa rho mania trim d0iodt fdfatlae dry an daft at twit rat elm sae aaYrClrp raseiae atBd.of
tCaaafaade 60 ARh eYr bon
,.mll�lt,YpfnYad ere addhtellet ANN ra0rfj IYa eama a/da del that rert0'ONEW
r��dt•--�yWWrxQa�COUpfu0tl0/baryuwf*rmYf 1F&*w1F&e00Arqy�rtj.&lft
Insurance Company Name
Policy 0 at Self-inn.Lie.ti Expwadoe Date
Jab Site Addreaa City/State/Lip
AtteeY a copy of the workere'nmpewdoa potley deelaratlan papa(showing the Poft na mbar and apUatlon 42te)6
Failure to am=eoveagd ere requited under Section 25A of MOL a 132 can lad to the
lone up to S1.500.00 and/or one-year imprisomaeat,as well u civi) �d0P WORK al DER an of Ji
of up to 3230.00 a day against the violamr. Be advised tbse a is to may
o e STOP WORK ORDER and a Are
Investigations of the DIA far insurance coverage variApQoe, old stt100mea may farverded to the Oflta of
/Jo hat8r Coat aw�p rAepe/we swfOmrdafa o/Pti/ay t/ket rAr/A/arwepon provl/c/above 4 urea and coffees
iianatunr ti"`�l 21 3 o G
y 7x- 42o- 4/3z7
Phone t" /
QQield are oa4t Do art wrke In A"8re4 to be cgno M/bP c14 or lowoQ46d
City or Town; Permlt/Liceass I
[ssulag Authority(circle one):
1. Board of Health 2.Building Department 3.Chy/rown Clerk a Electrical Inspector S Plumbing Inspector
b.Other
Contact Penor Phone M
Information an(I insiruci<l%YuJ fat their
emploYeea
y�achusess Genail Laws u de6a ay Ws mminn the�s«viee of Y COn"d otbise.
purstunt to the adata.an r
eapcesss or imp"ad or amuse.' r lepi aft.or MY two of_
A6 N-r'-+` m de8oed as rat iod[vidusl.V-' gyp of a deenfed MPWVW-lla*avac s
60
of the foregttiag eatRf� s joins a socisdot at othw�esntY, 6 Pl*y"L
receive[as nt,Us of an isavidw�patmwsm who c sida therein6 at the ootatpsat of the
mot macs det thtasud�nMpsk hoar
dwellms banns of
amp ug shill net beesuss o[ uVw1mew be d00° m be r
at om the i
arbtnldlaf sPP�i°t
or
MOL ahaPwr 152.125aQ also states that rr saw btu AVOO�O0�•fW am
reme�wsl sf a stoma er Peromb a ePer'a ���of aapllasa` ebs imatrates ewersp revir r�
- -- 'PPdC1mt"'bm br men predo14 WA7)' -NO-Mw the eommam""C nor 8nY of its politicil wg moo.
Additlaoa119,A[CiI.chsPmt 1s2,123C(3� -121111��wad-�e le°�^deOa of eomPliat►ee- ------ - -
CUMof this�bwe P�oo ms eaau.cth><at�orrtY•. -
retlitivilums
Aplkft"b affidavit eomPd�y.by�eakiog the boxes that apply oo your solos m4 it
plena Sri out the s)ss iesi name(6)6
u7 (Lm)taad
dL phoin u Pumushio aumbae(s)along w> ) �°thm
necesun
oes boo
members or parses•we so m am warkas• Oet fitted*cLt��or L>Of
•policy is m Be advised rhea this affidavit rmy be mb�d�tla '��"h s�ht
of insurance cwnap& Ado be sane is sip sat de 1)epstd�of
Accidtmts for comlhmstwo. tha parmit a tieeuss is being
be retaraed m the city or tows Ihat the prdWg ds taw or ityan ors requkred m obdim s workers
iadu�W Aaidm� Should yam have coy m xsdd below. Self-ittsuted caeopsnies sisould carat their
eonommom policy.pdwM caII&a DePOOMM Pas.
self-iosu °�bsr as do
apimnbm
Cj ar Totem Ofadsls at the bottom
Pleas be me that the affidavit is compic"and printed legibly. Ths Depatement bee provided s s�
Of the affidavit for You to nL eat in the event the Office of Invaliptioos has to conmet you rgPrft$the applic"
mtmber which will be used 0 a refweaco number. It addi i^an ap Hc"
plena be curs to illl m the peamtt/lieeaas m any
Siva yen,used oily sttbmu one affidavit iodicatiuP t 109
WAOU rip �/!( d widerap -Job one Site in
the applicant should wrie ran lacedoaa in�jt 1lY or
policy infornatiou(if aOcOmthat ha bees ofAcWIY soaped ar marked by tits city a town may be provided m the
tows)r A copy of dtt affidavit or lieasea. A new aM&vie moat bs filled
ft for_ out
arado she or ifildsilit u°�°ins s HMO"ar�pamk not related to MY budaess or comsat'�
y to bat laves cm)aid ptasom is NOT required m cOmpled"affidsv'L
(La. a dog&,=a or Pw°� and should you have any gwwdD0s4
The offies of tavestivaom wowd like to thank Yen in advaaue for your eooperenam
Please do oce haitm to give us a all
The Departnteae�a adds.teleph
res one and fia mtmbw-
Tba COMMaw"A of MmW useia
Depubned of jndowid Amdeua
Olda of Iivadptloss
600 Wultin600a Sftd
Boaters.MA 02111
TOL 4 617-727-4900 eat 406 at 1477-MASSAFR
Fuc 6 617-M-7749
Revised 5-2t545 WwwmLt Vv/dli
Crry OF SALEM
PUBLIC PROPERLY
DEPAXrMBNT
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Debdq d ds p wAdow dMM s 406•54
a�rdl r bti bnoed wG�d~.�cdo.m.e m.deed.�►s Oaeet :< ..
M wok AM bo depowd o(it a peopeely lemnd www d*wd&d ft sm doQnd by M(L s
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