29 VALLEY ST - BUILDING INSPECTION What is the Current use of the Building? ez
Material of Building?
If dwelling.how many units?
Will the BuilanV Conform to Law? Q S
Asbestos?
Archited's Name
Address and Phone l 1
Mechanic's NamS �
Address and Phone
Construction Supervisors License HIC Registration to l
Estimated Cost o ad S. permit Fee Cal W_W
Permit Fee$ Estimated Cost X$741000 Residential
Estimated Cost X S11IS100o Commercial-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 above stated
specifications. Signed under penalty of perjury X Cyr—
Date—�2--�
0
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o � as
4
CITY OF SALEM
' PUBLIC PROPRERTY
a DEPARTMENT
RIAMI..KLEY URISCt».
1�2N yo1, 120 WAST UNGTON STREET ♦SALEM,MASSAC:I-WSETTS 01970
TsL:978-745-9595 ♦PAY:978-7449846
Construction Debris Disposal Affidavit
(required ror 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of rapylity)
�'Ut as
(address of facility)
signature of permit applicant
date
debrisa(f doc
CITY OF SALEM
ki& PUBLIC PROPRERTY
DEPARTMENT
anasataT ramrod
MATOa
t20WAtF@I(.T0Nft%1ET.SAt.134MAUA0g,= R0lW0
74s:97I-745-959S .Fax:M740.9M
Workers' Compensadon Insuranee Afadavit: BuildowcontractorwMettr1daum mben Anadcant Informadom Pltia 1>Mt e Legibly
Name(Busies Y /��`�
Address' < l�j l —w�0 o d hla &� "� 4
City/Sttltea'Zip:___ � ��r Phone
Are you a employer?Cheek the appropriate boat _
1.Q I am a employer with 4. Q I am a gonad comacter and IFRemoMing
( :
employes(&K andler part time).• have hired the wbeontractnn truction
2.Q 1 am a sole proprietor or partner. listed on the attachad shoat,t gship and lave no employees These have working for me m any capacity. workers'COOP.i ssuance n[No workers'comp.insuresee 5. Q We am a corporation and its gddition
required.] o9icars have exercised their I O.Q Electrical repairs or additiow
3.Q I am a homeowner doing all work right of exmnptiou pm MOL 11.13 PIumbing repairs or additions
myself.[No workers'comp. a 15Z 41(41 and we have no 12.[3 Roof tepain
»rasrranea required)t employees.[No wall=, 13.❑Other_ COOP,issuance required)
r Hemeowmn wbe mft*dds adedwk Wd t muman as don reecho s d ra*wd am araakme'aompreredre Pik bdbemrtloa
tcamraetaee Am cbeek tide boa mom warlord roes oad�cad rem 4b amlds emaaerr 1 mug ai6ioh a am sNdnb te�g e�
ahoader rbe came of the tied drlr eabna'calm,Peaer i
laar aver earploya that b provldinj workers'eoapensadon Wurance or
ftmdm
lnjorwodota j nrY anployees Below is tAre pogcp and Jot ties
Insurance Company Name: \U �.11, l .
Policy#or Self-ins tic.#-- 1'a r)S( Expiration Date: — y�
Job Site Adarar.
City/Stue/Zip:
Attach a copy of the workers'eompemadou policy declaration page(sM the
Failure to secure coven tar wing Policy number sad esPtradoa date}
pr required Section 25A of MGL a 152 can lead O the imposition of criminal penalties of a
fur up to S 1,500.00 and/or one-year, as well as civil penalties in the form of a STOP WORK ORDER and a&a
of up to$250.00 a day against the violate. Be advised thin a copy of this statement may be forwarded to the Office of
Investigations of the DIA for WMWA CO coverage verificatiea.
l do Aereb)cerdA under dupebrs and paralder ojperimy that At injororodon provided above 4 true and tarred
OJjlcld use only, Do not writ be INS area,to be eosrpkW by c4 or lows Offlek(
City or Town: PermItTieease#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.Cityfrown Clef
6.Other k 4. Electrical Inspector S.Plumbing Inspector
Contact Person
Phone#:
PUBLIC PROPERTY
DEPART MEINT
KINGWA RY nR,er.vL
MAYOR 130 WASMNG M h MW#&MMk.%tnfsaalLsc'rtT 01970
TEL-97 US-M•PAX 9714740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEIMOLITION, OR CHANGE OF USE OR OCCUPAN _ _ FOR ANY EXISTING
STRUCTURE ORS'I'RUCTURE OR WELD.
1.0 SITE INFORMATION
Location Name: Building:
Prop"Address:
— - -
Property is k>cated In a;Conservatlon Area Y/N Historic Distrid YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: u
OK
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 (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
\ hSkall v �n� � S,�tno,
--- - -- Mail Permit to: -'�t-l— nw `C>Zsl� CS L