30 UNION ST - BUILDING INSPECTION � s
What is the current use of the Building? `
Material of Buikting? ^^'° if dwelling•how many units?
Wit the Building Conform to
�n r� Asbestos?
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Archited'sName
Address and Phone
Meehanie's Name
Address and Phone
Construction Supervisors Ucense 0 HIC Registration 0 /00 /6 '7
Estimated Cost OOff Prro�le�ct= Permit Fee Cakxilatim
Permit Fee i — Estimated Cost X$7n1000 Residential
Estimated Cost X S11IS1000 Commercial
AnAdditional $5.00 is added as an
Administrable charge.
Make sure that all flelds are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above
'stated
speciflcatione. Signed under penalty of perjury X
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PUBLIC PROPERTY
DEPAR'TMEN'T
KID,oeSICLAL
w.ro.
130 WASl1tI1414W S1wElsT 0 1MAK MAMAOq:SlYIS 01970
TEL M745.9s"9 F3t M740.%"
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION.
DEM LITION OR CHANGE S OR FOR EXI TIN
O E OF USE OCCC��N['y. ANY S G
STRUCTURE OR BUILDIN .
1.0 SITE INFORMATION
Location Name: Burg
Property Address: -
Property Is located In a:Conservation Area Y/N Historic DWMd YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner o1 Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTJM0 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(so Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work.
Mail Permit to:
L
CrrY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
ttatamua,r o.aocou.
w►rooa uo.�et:roreStserr.s�tat.11waaa+taatrtra1970
Th.W W454 SU.FAX 97W4tl9W
Workm"Compeandan Iummu a Afddavltt BalldwWCoa
Anadnat Informatba
pI ..te.t,..r..awe.
Name t .
Address:
Ciry/StatdZIp 2_ phone f$ _ °!7'r - 7 VS'- -s a e Q--
AN you u empYyer!Cbeek tb appropriate ben
1.Ell sa a employer wilh 4 ❑ I ue s genre)oedtraeaor and i �1M���
attrplsyae(ra addler put-dw4e have hired the ❑New emaoortiao
2.0 I am n sole pNprkea a pvmtee. )feed an the adsorbed]heel t I. ❑Remodeling
ship and have no empbyaa These abooeaaaae haw R Q Demolitlaa
working for Use be any capacity. workete'Camp.M* mu d¢e.
(No worhms'oomph mourance 3. Q We are s corpars"and ill 9• Q 8ailding addt =
required.) otRaeee haw eraeoised their 10.13 EIGMAGl repairs or add(dom+
3.[31 am a homeowner doing an work right of exemption par MOL 11.Q Phrmbing repaim or addidom
myself(No workers'comp a. 132.11(41 and we have no 12.Q Roof repan
rasu:roa requistAl t empbyea.(No workers' 13.[3 Others
camp�required)
*AV WOMO o+dadre Tat of era dae la ab ra redo haktMasly tbiwaelar'
Hero....w Made MeaM&*"Mks 6Wwdoiaadw*ad6.tdi.arwoa .��amdwwa+rrrs
rCa.e.etm os Meek ride bat row aaaeeai r dditimd drat dnelta ar.eaa aria rr eee►ra'aw Dell Wketi."
!air a r oayfayn A w br proviAwj wontas'eowp"sff6M&XW4 ere for uel eMfflky e+ grant b
In tAr ore/ 01 star
my Insurance Comp Name: Pegel I
Policy d+or Self-ins Lic. 3j�— 3 1 Expiration Daw.. 3 /2Pf D f—
lab sw Add. I -gym _ _ , CityiSeueraip:_ ya1 d 61, 9744
Attack a copy of the workerae compeoadoa po&y dwkrsden pap(showbsg the poBey number cad sxphradon date}
Faihue m secure covange as required under Seedon 23A of MOL c. 132 can lead to the impoddon of"besioni pmdtip of a
furs up to S 1.500.00 and/or Goo-year imprisonment,as well as civil pendda in the form of a STOP WORIC ORDER add a Ana of up to S2S0.00 A day against the viob Aw. Be advised the a copy of this ateemeat may be fotwvdad to the Ot]fu of
Investigadoma of the DU for utsvana coverage veriAtadoe
!do Aerebp eerath snda A#PWM and pewdda of perjury that tAa/nfotmadow provided abort'Is tree awd torreea
Sianuure• Qy
Phone M 7 h — ?
OfJfe/d use oa/J1 Do not wdte In this ernes to be cospfatd by c4 of Aiwa of)fe%(
City or Tows: Permlt/Cieeap p
Issuing Authority(circle one);
i. Board of Health 2.Building Department 3.Cityftown Clerk d. Electrical Inspector S. Plumbing Inspector
6 Other
Contact Persod• Phone N __
6
CITY OF SALEM
0*-ts;
PUBLIC PROPRERTY
DEPARTMENT
naisa:ai.
LG IXUini\c o�5�ataeT �5.1t.f��f,�tnsiac;us�rn�t97C
Trt:978J45-9595 # F..%x:978-74G984h
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 111.3
Debris, and the provisions ofMGL 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
111, S 150A.
The debris will be transported by:
iname of- - hat
The debris will be disposed of in
(name of facility)I
l address of faCitity)
si�catu1permitappiir t
gate