8 WARNER ST - BUILDING INSPECTION What is the current use of the Building? '
Material of Building? Wo cz rRRF� If dwelling.how many units? No�r----
Wilt the Building Conform to law?
Asbestos?
Architect's Name
Address and Phone
Mechanie'sName ti1G�� rr �lqp 6 a/ ! lZSl���7s%S�
Address and Phone �� �9ii2 �iEEv EP/7
Construction Su pervism U nse S �`^93 � HIC Registration M
it Fee Cak:uWon
Estimated Coat of Project �! Perm
0 Estimated Cost X$7J$1000 Residential
Permit Fee$
_ - Estimated Cost X$11/$1000 Commercia4-----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.
7 �
�? The undersigned does hereby apply for a Building Permit to build to the above stated
�0 ���",sue
specifications. Signed under penalty of perjury X
Date
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za �
4 LS 333
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e
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR TMENT
tcnratuttstt t>,tacou
MAW*
uo vt ,Snrsr a stay,l/asaaattssrts otgro
TM-M?4&"% a FAX tW40.%%
Worketa' Compenution Insurance Affidavit: BuUduWContractoyMKp{danyphymbm
AanHnnt Inhrmsdot n print r tdbly
Name( )
Address '� oL 1=A:1' vices ff.Pi2
City/S i!�/g phone V. 7 0V- 3 a/zs��
Are you an empbyerT Cheek tha approp.lab best
1.❑ I sm a empbyar with 4. ❑ I am a p oard eontrutar and I TylM er Pwjeft
2.—�pl (1W1 anNor part-time).* have kited the wbeonpae� 6. ❑New cmaRucaon
Y2r1 am a sob proprietor are partner. listed on the attached sheet.t 7. ��Qmodeling
ship and have no employees These mb•mntrscoOo have t, ❑Demolition
far me to any capacity. workerst comp,ioas atree
q •comp insurance 3• ❑ we am a�m and its to ❑ won
3.❑ 1 am a homeowner doing all work right of ized dean ❑ IOP at addidcas
myself.[No workma• a IS aernptlep Pm MGL 11.❑Plumbing regain a addidons
romp 2. 1 4
e ( b and we have ro 12.❑Rootrt pain
rn�°C0�)t �PleYeon(No warkme•
c�P maaaaa required.) 13.0 Otka
''Any
rep vft a u daww �ir rat go w am te..stlo.trio.ao. ,6rr,b,�y v�r blesertra
tCmaauwe ar cbadt dda ear maw� �d a*tM ees Or aisles aatawws mow satmdt•am striven�tart dssriry rim ear ddr demaaemw ad edr wmton•am*paltry inhand e.
f am an ea lsbW fhad IsProvldbtf workers'compeneades harrow e a
lejoratattaa J my faaPpYsea Bdow 4 NYe poBey anfJae rip
Insurance Company Name:
Policy 4 or Self-ins.Lic.N
Expiration Data.
Job Site Address:
C1WSuuLrzip:
Attack a Copy of the workers'Compesudon policy deeluadon pap(s►ewir eke
Failure to serum covers u g Pow number sad ez*sdoa dab}
p required under Section 25A of MGL c. 1 S2 can lead to the imposition of fa
fine up to!1,500.00 and/or one-year imprisonment as crimioa)peaaldes o
well as civil payldes in the form of a STOP WORK ORDER and a Ras
Of up to 32S0.00 a day against the violator. Be advised that it copy of this statement may be forwarded to the office of
fnvcstigsdou of the DIA for insuraws coverap verification
f do hereby cadA under A#pans and pena/dp oJprr/wy that at InJorntadon rovldd P above L 4rtrt and Coffees
S'tsnatum• �������
Phone M!
Olkid me oft/A Do not write In this area,to be coetpfstsd by c&y or town ofrfelal
City or Town: Permlf/I krone N
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cltyllbwn Clerk 4. E)ectrfcal Inspector S.Plumbing Inspector
6.Other
Contact Person:
Phone 0:
CITY OF S ALEM
5 , I PUBLIC PROPRERTY
DEPARTMENT
K1\160:KLFY WhOIAr.
\1arcR 120 WASHINGTON STREET • SALF.M.:VIASSAG tL.SL715 01970
TGI:978-745-9595 4 FAs:978-7449846
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
111, S 150A.
The
debris will be transported by:
C0414,V�
(came of hauler)
The debris will be disposed of in
(name of facility)
4 i`� �NBwNI
laddress of facility)
sig.aturc of�it applicant
A 7
date
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Cy oo- / ap6711
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Ma�
EIT�
DEPAOF-'
PUBLIC PROPERTY
RTMENT
KIMMLLY OUSCOLL
MAYOR
t 30 WMM wT(W4 SMW 9 SJMkAk NLAMAO¢Strrs 01970
74191&71S-9S9S•FAX 976740.gM6
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUC—MR OR WELDING
1.0 SITE INFORMATION
Location Name. / C/j C iy $ v Building:
Property Address - — - -
Gl�
Property is located in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
S ,71e1Ve,0 S'7`
Telephone: / - 7 $ - 7 Y`
3.0 COMPLETE THIS SECTION FOR WORK IN EXI321Np BUILDINGS ONLY
Addition Existing
RenoEin
Number of Stories Renovated
Chane New
Demolition Existing
Approximate year of Area per floor NO Renovated
construction or renovation
of existing building New
Bosef Description of Proposed Work:f7
/
-- -- -- Mail Permit to: