32 PUTNAM ST - BUILDING INSPECTION YJhat is the current use of the Building?
Material of Building? If dwelling,how many units?�—
Asbestos?
WIN the Building Conform to Law?
Architect's Name
Address and Phone
e `mod �6 ,ter
Mechanic's Name
Address and phone S- /S I r�
Construction supervisors isors License O 7 le >1 HIC Registration p D �'��-
Estimated Cost of Pro' $
GS00 . Permit Fso Calailatlon
Permit Fee S Estimated Cost X$7/111000 Residential
Estimated Cost X$41/$1000 Cormmercial--_.__-__
An Additional S5.00 is added as an
Administative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
v;peffnit
tob
ufld to the abo to
The undersigned does hereby apply for Buildingfor
specifications. Signed under penalty of perjury
Date
a
. EIT'�-OFF
PUBLIC PROPERTY
DEPARTIVIENT n ��
ri.mFs�sr p.R,,v J. r/
MAYM 120 WAMUN W sneer•SALXK Slwstna4Us��-rs 01970
To-976-7454S"•PAZ976-740-960
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPAM-Y FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: //cfro o z S 9uliding:
P►�nY
Address:
P Property is bested In a;Conservation Ares Y/N r/ Historic DWWd Y/N
IY 2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: lfcl l V
_ Address:
d- //7 c, Grt
� Telephone: c
3.0 COMPLETE THIS SECTION FOR WORK.IN EXISTING BUILDINGS ONL
Y
Addition Existing
Renovation Number of Stories Ren ousted r
q.
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) LRenovated
construction or renovation
of existing building New
firief Description of Proposed Work:
1 �
o L
1
Mail Permit to: toot,"-.-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wtvtnt AIZY ualSt:uu.
w1Avtst i2CWAAHLNCroteSntkfT0SALEM.MAs,ACI[F-W IN0197J
Thl:97t-743.9393 4 FAX:9M74L%9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information c! /n / Please Print Leeibly
Name tBumnessiorgani:ationandivtdual): /J� r / �N //&/C f Z
Address: S�/g j ew A41Co C✓ i¢t,C—
City/Starcizip: ����1-*;7 /'hone d: 57 )S
Arc you . employer? Check the appropriate boa: „ . 'fype orprojoct(required):
1. am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-tine).• have hired the sub-cuntractors -
2.❑ I ant a sole proprietor or partner- listed on the attached sheet. ; 7. ❑ Remodeling
ship and have no omployucs These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp, insurance. 9. Q Building addition
,[Ko workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions
myself.(No workers comp. c. 152,§1(4),and we have no 12.❑ Ruof repars
insurance required.i t employees. [No workers'
13.❑ Other
comp. insurance required.]
.Arty applicant our cltccks boa NI must also till twl the section btduw howiag ib it wwksva'cumpanudiwt policy iofureu'
'it.rm.wwnsrs who submit this affidavit indicating they arm doing all work and thm Ein Wifida cootraaoa muat.uhrnir a new amdavit indieaing uteh.
:Conrrxvws that chuck this box must artached m additional dwo.howing tha nsata or the rub-contractors and their workers'comp.policy informadon.
/an;(its amplayer that Is providing workers'compensation Insurancejor rrry employees. Below Is the polity and fob site
iujarmation. /�f l
Insurance Company Name:^/><./r,' ,)i an- .-_' e-1
Policy 4 or Self-ins. Lic. 4-&SSO77•_ Expirution Date: -S U
Job Site Address: Cityistate/Zip:
attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A of y1GL c. 152 can lead to the imposition of criminal penalties of a
6ne up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to S250.00 a day aguinst the violator. Ile advised that a copy of this statement may be forwarded to the 011ice of
Imeangatiutts ufthu DIA for insurance coverage vcriticatiun.
1 da hereby certify ur er the pains nd "it" of erjury that the in/brmadan provided above is true 'nd correct.
�i •aature' _ Dar .
u 7 /
OJfTcial use ardx, nu not write In dds area,lobe ruurplrled by city or Town ufJlt iaL
City or'rovrn: Permit/License q____ _.
Issuing Authority (circle one):
I. Board of ucalth 2. Building Department 3.Citj/fown Clerk 3. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: - - __ Phone N:
��- CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I.V'Am.01L
QC WASI"I :OP11?EFT 0 SAU.M.
TV:VM743 5" F.\x 9M74G9i46
Construction Debris Disposal Afttdavit
(required for all demolition am renovation work)
In accord&= with the sixth edition of the State Building Code, 7S0 Cb1R scetion 111.5
Debris, and the provisions of MGL c 40, S 54;
Building{ Permit M
_ is issued with the condition that the debris resulting from
this work shall be disposod of in a properly licensed waste disposal facility as deRned by MGL e
111.S 150A.
The debris will be transported by:
' Ii=ma of haul
The debris will be disposed of in
wwne of'ia2111ty)
0 / G
1