23 WARREN ST - BUILDING INSPECTION (2) EITY-OFSALE. -
APUBLIC PROPERTY
DEPARTMENT
I:I�WF.IILEY DRISI:ULL
MAYOR 120 WACHINGTom b.nLEEr•SALEK WASSACHLSL1-M 01970
1471 97 8-7 4 5.959S♦FAX 97&740-9846
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: T �fi( (y�nn S rC 5�� � - Building:
Property Address: �:5 q4 ��Z) (ft
props ty is located in a; Conservation Area Y Historic DI Y N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: a 3 �kXYleA- '
t5a 2 rw�- o
Telephone;
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing a
Renovation ✓ Number of Stories Renovated
Change in Use New
Demolition Existing S
Approximate year of b /� Area per floor (soRenovated d' S *
construction or renovation b / 15-0 '51-Pf— New
of existing building
Brief Description of Proposed Work:
Mail Permit to: ��
r
What is the current use of the Building?
Material of Building? W OO O( If dwelling. how many units? 1
Will the Building Conform to Law? Asbestos? h
Architect's Name
Address and Phone
Mechanic's Name tr
Address and Phone I O L
Construction Supervisors License# y 4q l ;L, HIC Registration# b �J S 6
Estimated Cost of Project$ O00'&-0 Permit Fee CalculaWn
Permit Fee$ GI -C-0 Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
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 Permit to build to the above stated
specifications. Signed under penalty of perjury
Date 3 � b
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CITY OF SALEM Hh G 10
PUBLIC PROPRERTY
DEPARTMENT
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M VASIOWONSTMT.SUMO MAsg►QRmrM 0197o
TEL 97L743-959S a Pax:97t74t19M
Workers' Compensation Insuranee Atlidavit: Rudders/ContractorsMettr c am/plramben
Applicant Information Ple e. nt r.id .ti
Name ):
Address: �a c� ��
city/statwzp: Phone#_ 7—LT— -'7-7-(—
Are you an employer?Cheek the appropriate best
1.❑ I am a employer with 4. 19I am a general contractor and I Typo of project(keoswareo
employup(fishand/or part time).• have hired the sub.conaa []New 6. New construction
2.w7 am a sole proprietor or partner. listed OR the attached about,t 7. []Remodeling
ship and have no
n These working for we in any capacity. p•'com have 8• ❑Demolition
(No workers'comp.insurance 5. ❑ We ace a corporation and its 9. El Ong addition
required.) officers have exercised their 10.1.Electrical repain or additiooa
3.❑ 1 am a honmwnw doing all work right of
uctoption myself.(No workers'eo Pre MOL 11.(apoofre g repairs or adatlow
rep. a 152,�l(4�aril aro have no 12.
13
insurance required.)t employees.[No Workers' 13.❑Othurre�comp insurance required
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Insurance Company Name:
Policy#or Self-ha Lic N
Expiration Date•
Job site address: Cary/atatellip:
Attack a copy of the workers'compausdam potley deehentioa page(oho the
Failure w secure coverageu �L Po�7 number and expiration daps
required under Section 25A of a 132 can lead to the imPoaitim of criminal Penalties of a
foot up m 31500
, a d and/or ,-Yew imprisonment'as wen u civil penalties in tits form of a STOP WORK ORDER and a rise
of up to$250.00 a day against the violater. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby tral/y a r AfPaim and prnaldex ojperJary that rho Injorwadon provided abort 4 taws and corset
Phone* 4L 7-
FIssuing
onIA Do not write In this area,to be Completed by city or town oQfcfa(
CityTown: Permlt/I.Ieease N
hority(circle one):
Health 2.Building Department 3.Clty/rowa Clerk 4. Electrical Inspector S.Plumbing Inspector
soa
Phone 0:
i
Norwood Electric
Peabody, MA
978-535-4480
Harris Plumbing and Heating
Gloucester, MA
978-282-7473
KELLY TYLER
23 WARREN STREET
SALEM, MASSACHUSETTS 01
March 13, 2007
Mr. Thomas St. Pierre
City of Salem Building Commissioner
120 Washington Street
Salem, MA 01970
Dear Mr. St. Pierre,
As I mentioned today, Ed Bruenjes is remodeling a second floor bathroom at the home of my
husband, Nick Lewis, and I at 23 Warren Street, Salem. Ed expected to start framing today,
but was called away to Manchester on another project. When I reached him, he said he was
planning on coming to Salem this afternoon to apply for our building permit. I offered to
head down to the office and take care of it for him so he wouldn't have to make the drive.
When I went through the forms, however, I see that I can't provide all the information and
signatures, and also can't provide a copy of his license. (Ed tells me that he has other permits
pending or on file in Salem, so permits there is a copy of his license attached to one of those.)
I haven't been able to reach him again this afternoon, so I thought I'd submit the partially
completed application and a check for the fee. Ed expects to be in Manchester again
tomorrow; I'll talk to him about completing the application requirements as soon as possible
if you can kindly hold on to this packet.
Many thanks for your assistance.
Sincere re g -dy, 4
L
YY �
'ell Tyler
Nick Lewis
978-744-2755
WWW.THELOSTMEN.COM 0 KTYLER@ POST.HARVARD.EDU