78 VALLEY ST - BUILDING INSPECTION a
I
What is the curcent use of the Building? It how many units?-- —
Material of Building? Asbestos?
Wilt tit•Building Confom►to Law?
p rcKdeds Name
Address and Phone
Mechanic's Name Ctil 1 ��-- L�^rn 0 78'1
Address and phor" HIC Regbtratkut*4V1 778
Construction Supervisors License to
Estimated Cost oisd S S!- 000,0 O Permit Fee CalarMM
Permit Fee S Estimated Cost X$7/$1000 Residential
- EsWnated Cost X$111:10011 CommmcW —'
- An Additional$5.00 is added as an
Administrative Charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Perm to build to the above stated
speciricatione. Signed under penalty of penury X Olv-2 �'``"'�
Date o
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o
sal
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PUBLIC PROPERTY
DEPARTzm&NT
IJ..OIEtl.6Y Duscwl
V wroe 130 WA"XC"Sfts •
SMAWMA0Aap:S6T1s 01970
TM-rt-7454M•FAX 97L740.g"
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
OCCUPA
DEMOLITION, OR CHANGE OF USE OR M FOR ANY EXISTING
STRUCTURE OR BUILDOG
1.0 SITE INFORMATION
Location Nanw SAuJ' SuildhV
Property Address: - - - -
V a llr° ✓y7gS'-y
Properly Is located h a:Consarvatlon Area YIN Historic 01suld Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 9613 w,'•7
Address:
79 a o
3.0 COMPLETE THIS SECTION FOR WORK IN EXISllNG 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
Brief Description of Proposed Work.-
Mail Permit to: " P,Qo/la S71- Z-y,, I /✓less ��fl _ ._
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
rnnaatar o.uooe.e.
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Plti..ts►e.r Loamy•r.z_I ll �aM iPa.�,,� 5Q
Adslrem_ /� 1�P�?ona �4--
cityistale/ZIae 1, I o o�dTy Pboae
A yet•=mpkyu Check W Appropriate teas
t. I as a employer watt 4• ❑ I Sn a!bent combater and I Type���
n
at ovioyer am=Ner put•dw4o & 13 Nsw C°Ostracdon
2.❑ I aea a sole psoprleer or puma Rued ass the Michell ahnL t 7. ❑Remode ft
ship and have=ampipyess Those ma000amck n taw L Q DwwHdon
worries the me Is aft Capacity. wadmw camp inbamoa
(Ale wodmW camp insurance 3. ❑ We sn a cmPende a and its 9. E3 Ruildfog addidm
3.01nh�pwmr omens have eratdsd— , 10.[]Eleeuiaal sapdn a addklows
all work dphe atesmv"Per MOL l I.[3 nm*f f NPWM or addidone
mynK(No workess'comp a 132,11M ad via have no 12
enattrSoa t Imavoe( •� 13�Oehar_L1/_ I°�_
;And q/Yes*A dons ba et aiw do m o do ssda Aste.dtrey askearasw'
H I Wderahmlei lis 11, ahirotlyn4 awdoYrdeaiaieaYwauWe a�itnimk tCamrus dtr abut dda box am dashed a add dmd Show w draabtr do orb larorty sosl
ad►eearadrs ra dtatr aarhae'oaf Pacer 1a�
lamtier bP "M V e WkM'eawPearadew Gs WkVJir AW eayfoyesa defmr b tAaPaHep aa/Je1 sib
Insurance Company Naar._
Polity N a Sdt--iom,Lie. 11- Mepirai adan Dab. a$-
la®Sib Address Va (I!`y s'�— cur�sewzip S f
AttatY■copy a<!het erorkSn'eomPaasadoa potlry deciaracka Pap(ahowle{the Pam ntanher Said aPkStkS dab}
Feib"to secure Covmpe"reeptited under Seeds 23A of MOL a. 132 can led to the impoddm otaeimimd fine up to f 1,300.00 awr on
one-yar imprisonment as well as Civil man in the form of a STOP WORK ORDER a w a fine
of up to$230.00 S day aplimu the viohuat Be advised that A copy of thin statement may be forwarded to the Oflta of
investiPdom of the DIA for insurance covmp vedIIeados
f do kerdP ce and"tb paint an/PenaMw oJPn/ary the the laye►awd"
Pfew !t trw awf eorract
/6 Q
Phone
O,QIeld Sae oafjl De dot wrlta G CAL arts,r,lei eaesPleta/IP eilp a totes ofJk/al
City or Towas Pernsfo keaso•
Issuing Authority(circle oae)t
1. Board of Health 2. BuUdIS,DepSrtmeat 1.Clry
d. Other frown Clerk 4. flectried Inspector S.Plumbing Inspector
Contact Person: OL.__
CITY OF SALEM
PUBLIC PROPRERTY
97 � DEPARTMENT
n;\I GiRLtl'!'Kiiiail 1.
\l.0(�K 130 W.\91NG-i OH STREET •SALFM. Sf.Ui.1CHL,,L l-i S 0191C
,rn:978.745 9595 •F.+.x:978-7+49846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 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 1.50A.
The debris will be transported by:
----- dG ----
(name of hauler)
Hie debris will be disposed of in
(bame of facility)
G
--- - uuldms. ofCacilhy'1
--....- ilglwture of pdnnit ap( ant '
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