12B RUSSELL DR - BUILDING INSPECTION What is the current use of the Building?
Material of Building? �o it dwelling.how many units?Asbestos? NA
win the Building Conform to w?
y � .---
Architect's Name
Address and Phone NSA
MeehaniWesName bed �f�'P�•rc SAS 5 � (Y' '//(' z,
Address and Phone D/ g 3 -C —
Constructim supervisors License# HIC Registration#
Estimated Cost of Project$3390� o= Permit Fee Cak: Won
3 ' D Estimated Cost X$7/$1000 Residential
permit Fees °
- _ Estimated Cost X s11/s1000 Commerdal-- -
- An Additional s5.00 is added as an
33 Administrative charge.
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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 pedury X
Date
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a C6
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xn.asasav oapcott
MAVM
12o WAM"UMST.W st,.a14SfwaaanMM01WO
TM 97147UM S o FAX 97L740-9W
Workers' Compemsadon Insurance Affidavit: Bnlldere/ContMtors/EleeMdam/pl�
Applicant Intormadom II P>" wM ■
ben
Name l Y-- 2a164�� J G,eu�cu�c
edbtt
Address: 14,i LJ a
Ciry/StataMp: Sa(z-� Mal o!,3-2v phoDe
An you an ompteyer7 Cheek eha appnprlab boss
1.❑ I am a employee with 4. ❑I an a gonad contractor and I T91M of fie)
empbayop(flan andlot pe4tims).• have hired the sub.contmctore 6. ❑New conwoodue
2. am a sole proprietor or partner, lured an the mmobed abort t 7. [3 Remodelint
ship and have no employon Thee wb.00namstas have L
working for we in any capacity. wakes'Comp monaw ❑Demolition
[No workers,Comp6 bMnM ce J. ❑ We area corporation sad its 9' 13 Building addition
required.) omcere hew exercised dmdr 10.13 Ekctripl repairs a+ddjdaes
3.❑ 1 am a homeowner doing an work right of exampdon per MOL 11.0 Plumbing repulm or additions
at rka 'comp. a. 152,;1(4),and we bow noRoampaim
e re4
t CMPWYCOL[No workers, 12.
COMP iaauaoos required.) 13.13 Odmr
t �mbnh W dmb di a do no as do raalaa twmr Amb41 lists emkms'ooepmuyr r vdlrr tadm "
tComaemm tar dM*tAh ton mart ease aMdwkdest g aftaMil hohiaa d emh ad a•tdw ow"ooroapaw mud abaft s ew stadrlr bdfeatlna raoL r6o.f etaroaMore.mbeamapopdredswm4a'comapoaar lowing ma
/am ww ewtpbrya that Lprov/dlwf workers'Cowpeeaadow L.".,, e� or
lwforwa" J oRYOMP10Yeea 9almo 6 tbo pO&7 ewdM sits
Insurance Company Name:
Policy M a<Self-iaa.Lic.M:
Expiration Date:
Job Site Addrea
CirylStatet2:ip:
Attach a copy of that nor Lora'wmpeeasdoa policy declare a pate(Sko the
Failure to secure coveragees � PoL7 number and oxPlradoa dats16
required undar Section 25A of MOL a 152 can lead to the imposition of eriminel
fine up to f 1,500.00 andla one-year imprisonment,as wen as civil penalties in the form of a STOP WORK ORDER amend of fine
Of up to 3250.00 a day against the viohuac. Be advised that a copy of this statement may be forwarded to the Office of
Investigation of the DIA for insurance coverage veritScatioa
/do hereby arN/y"der the pales and pewa/dq of'ptr*y char de/a
jonaadow provided above Is trw and tossed
- Ilia w S � c7 07
Sietature:
Phone
1 7 ?�- S 7 d'- �F I L z
Ofckd au Dula Do not write In this ore4,to be Coapletd by city or town ofJfew
City or Town: Permit/!Ieeme N
Issuing Authority(circle one):
1. Board of Health L Building Department 3.Cltylrowa perk 4. Electrical Inspector S.Plumbing Inspector
&Other
Contact Person:
Phone 0:
40 CITY OF SALEM
rl. l PUBLIC PROPRERTY
y_� DEPARTMENT
s;�mrx 1.r.1'r Ku :ca r.
110 WASI ZING"CON STREET • SALIA1,MASSA(ait.Sli 1-1 So'97:
'rr.l:978-745-9595 •FAX:978-740.9846
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
t 11, S 150A.
The debris will be transported by:
rN S%L --
- _-- (name of hauler)
The ddqcbris will be disposed of in
(name of facility
-----Se-Lc,w, 11-/9
IaSdress of factli[!/)
sivaturo panrat appuant
e7
„ate ---
J F�yy wry}
• / V i a 1 O3 � J
i.�
PUBLIC PROPERTY
DEPART11dEI
u..wWJU"DR15CWJ.
4Avon
130 WA"NOU*�''MEU•SALUK N.Nuan 50-M 01970
TM 973-745.9S"•FNC 97eb740.9"
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPAN FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION "
Location Name: Building:
- -
Property Address.---- -
Property is located in a;Conservation Area YM fJ Historic Distrk3 Y/N
3.0 OWNERSHIP INFORMATION
3.1 Owner of Land
Name: O-t cL- a Gc r o
Address:
12 --
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation 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
Bdef Description of Proposed Work:
�aLe, C 5� t �c, �2c�
Mail Perm ea-r ?- O n ��i flay co �T G�Prn I-1A__