78 TREMONT ST - BUILDING INSPECTION (2) What is the current use of the Building?
Material of Building? if dwelling,how many units?
Win the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone )
Mechanie's Name ff� #.> )
r� � �Address and Phone D 6Constnution Supervisors License S O7 . _HIC Reglstration 0
Estimated Cost Of Project i I Z6 O- Pernk Fee Cakwladon
Permit Fee i mod, - U Estimated Cost X$7/$1000 Residential
Estimated Cost X$111$100O Cornmemla�
An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the abov tat
specifications. Signed under penalty of perjury x
Date d l G
s N
e
or
_ J
Erry-oF-& En -
PUBLIC PROPERTY
_ DEPARTMEINT
XMIUM8Y ORMCWl U
MAYOR 120 WAPU2�4Z W S17Err�. yu&K.MAttA[H1:S611S 01970
TEL-978-74S•9S"•FAx:97L740AW
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING ,
1.0 SITE INFORMATION
Location Name: %& rfit`m v w Building:
- -- Property Address:_ -
Property is located in a: Conservation Area YIN AZHistoric District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: 1 yet u 4,07 C
Address: ( `
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK.IN ExI nud BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated gr=
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: /
71-
--- ---Mail Permit to: f` c�%.. D• r r'n uiac �¢L, C -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
st.unl�atr:r uatst:uu
MAYOR lY'WAsruwTavSTaehT 4 SALEM.MAssxctnaelts0197'J
TEL:978-745.9595 4 FAX:9711-7409946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information IC—ell/ / Please Print Leeibly
Name tHuaincwOrganiratioNlndivtduall: r OG/CZ �L
Address: /weed/ /¢eic:---
City/StarciZip: _*7 5$ Phone ll: 22rS '7% ����
\re you mployer? Check the appropriate box: Type of project(required):
1. ama employer with 0-1-- 4. ❑ 1 am a general contractor and 1 6: ❑ New construction
employees(full and/or part-tine).• have hired the sub-cuntractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet : �• ❑ Remodeling
ship and have no employoca These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
f no workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have cxcrcL%cd their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.) 13.❑ Other
•Any gpiicuu that checks boa el must also lit]"the section]snow dwwina their wotlem'cuntponwdoo puliey infumatiwr.
' Ilurntwnwren who submit this affidavit indicating they am doing all work and then him-owitide cmainctore most aumnit a new aMdavil indicaing such.
CorttrxYSKs that chock this boa mtaq anachad an additional Jsxt showing the ne rna otthe sub-comracton and their worker'comp.policy informarion.
fain an employer that ls providing workers'compcntndon lmsuranec for mry employees. Below is the polity and job site
iuforinution.
Insurance Company Name: /T✓yt 1 i C r<n, .-._ �//. [ //c .zn c o,
Policy#or SelGins. Lic.#: GL'/C ' tw Q �__ Expiration Date: -� 19
Job Site Address: Cityistate/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.vIGL c. 152 can lead to the imposition of criminal penalties of a
ti se up to S 1.500.01)and/or one-year imprisonment,as well us civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OILce of
lit%emigannna o1 the DIA for insurance coverage verinCailon.
/do hereby certify ut er�Ifsepainsnd alt'• of erjury that the information provided above is true nd correct.
tii :rnnre; I) t
n• •7
U/Jlc iu!use only Do not write In this area, to be completed by city or town oJ77cial
City or'rown: PermiU1.1cense
Issuing Authority (circle one):
I. Ilourd of lieallh 2. Building Department 3. Cit)frown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Cuulucl Person: __ Phone #:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
t 0!'A:v:l`1 L
\L�Uw I!C�T.�i1�N::Jtil.7t1T�1\Li4,5taciU::rta 11)i:91.
Tq:9 7174 5 159s F.%x:974NG9"
Construction Debris Disposal Affidavit
(required for all demolition am renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR section 111.3
Debris, and the provisions of M. GL a 40, 3 54;
Building permit N - . ._ is issued with the condition that the debris resulting from
this work shill be disposed of in a properly licensed waste disposal facility as defined by .IGL c
1 It.S 150A,
The debris will be transported by.
haul
ly
The debris will be disposed of in. :
tn:+mr ut'io2rlrty)-/`/�/
.d.:r.v Sri tScil,ry)
..1t�