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38 WASHINGTON SQ SOUTH - BUILDING INSPECTION What is the Current use of the Building? e �-how any units?_ice-- i o _ Material of Building? If dwelling, YrC Asbestos? "a the Building Conform to Law? A prchiteds Name IrIAAddress and Phone t? Mecltank's Name Address and Phone She e Construction Supervisors Ucense 0 t t_._-- i—HIC Registration 0 � 3 Project: Permit Fee Caleuistion Estimated Cost r c9 Estimated Cost X:7I$1000 Residential Permit Fee i �-q 0 0 _ Estimated Cost X$i 1lS1000 fAmmercial---- - _ J An Addnk)#W$6.00 is added as an Administrative charge. � 5 Make sure that all fields are property and legibly written to avoid delays in processing. The undersigned does hereby apply for a Buildup Permit ild to the abov fed specifications. Signed under penalty of perjury 3D Date r 1 N 3 j r � � ' -4: a `3 � � a CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT it\If:h Rl�'T I'fl11CU11. \Iaon I20 STREET •S.iLF.M.MASiACHLSL t-CS J191C Tn:978-74;-•r5e5 . r.,x:978a4a9846 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 I11. S 150A. The debris will be transported by: (name of hauler) Tlie debris will be disposed of in r _ u (nam o facility) AV6,3Lnn1A I:nlurcs. of faCi Gty) rn g��y.� ZZ2,y J V � sir:atwc of penric a(;plie [ ---- rs f 30, a2°°7 - ,tatt Y CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT MwVOR 120 WA%ffC OftMT a SMM4 M""CW MM 0L970 TEL 97L745•9S9s a FAX 9W40.9W Workers' Compensadou Insurance Atndavih Buaders/Contrae A ooticaet In_tormatlouIAtwa T.en.t.. Naate� :_ obe�f Q,^,ore jk P>-Q- Address._ _ Cl►y SQ— c(wstatdZip:_ s*A l�r.v_ ,�, �d?0 Phone Al. `�7F-3(7•-/06 0 Are you as @arpisyert Cheek eke apprepriate boss 1.p I am a MOWYR with 4. [31 am a pang contractor and I Type W Project(requited): 0�ployep(!loll and/or part-dm4* have hired the subwntraet. d' ❑Now emreticdne 2.L�J 1 am a sole paoprietor or 1prnta6 listed an the auaehed ahwt t 7. ji.8 ship and bans no employees These rob tan haw 11. p Demolition working forme in my eapadw• workers'COMB;nsuma� (No%wrim'Camp insuann 3. ❑ we as a corpssden and ih 9• p Ong addidaa ro4uirad] otIIcors have exembed tlair 10.p Electrical repairs or additions 3.p I am a homeowner doing all work right of a temptian par MOL 1 I.p Pdtmbing rapeis or addidom mysalt(IYs workers'comp a 152.41(41 and we haw no 12.p Raofrepsis insurance,required,)t employees.(No wodwat coMR manaooa required•] 13.p t7dtar ;Any N�y�eo�s i r e1dWn#d••ind �h M ore ...ala.Mlwe rteelq uatwoikra'osm0�loa odiry l lesde� tcomodm Orr neat dds ens mow ago"0&dgd M� •ak.t A.mn amfat oaYsasa vote alit a a w.nwMt iodine as tones MMOM� rho,hi/dr Hama fiat sateenaoasas red art ealoas'eomF PRHe7►damadea 1 am aw enrOlo w that is provld/nj wor"ro'cowOeneadea buatonee oe lAfafadtkut I my employees Below is&e jw&i.w/lok slat Insurance Company Name: Policy N or Self-iaa Lic.M Expiration Dew Job site Address CiwiStatvtp: Attack a copy of the workers'compewdon policy declaration page(sits the Failure to steam coverageY � POUCy number and expiration date} fine up to f 1,500.00 amor o��under O 23A of MGL a 132 can lead ro the imposition of criminal pesmidea of a Of up to f2S0.00 a ties a Y �PNO as well as civil penalties in the form of a STOP WORK ORDER and•line Y against the violawr. Be advised due a copy of this statement may be forwarded to the RDE a Investigations of the DIA for imsuamce coverage verification /do benby cud n r tits pal s an "Na 0Jper/ary that the In�ormadoa provldef above 1:sae and correct (7 ^ d Phone 0m, D,(jlcled au OXIA Do not write in rho area,to be complow by C4 or lows ohyelo( Ciro or Tows: Permlt/I.itesse N Issuing Authority(circle sae): I. Board of Health I.Building Department 3.Chty/row■Clerk 4. Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone Y• 1 EIZY-©Fg /o�� PUBLIC PROPERTY f� DEPART WUNT iu.�r oerscau. ,Jf, [�O �IwMOR T"� 130 1A"NI7".1,'M tiT•IM& MASSACKSh-M 01970 TM-MUMS"•PAX 97{I4&"K APPLICATION FOR 1[1111I: tILpA� NOVATrON CONc'rRUCTTON DEMOLITION O" OR BUIi STRU�CP mt�r >fllNr FOR EXI TIN 1.0 SITE INFORMATION • Location Name: t3uild(ngOASHi s 7 0 .� ESQ Souk Properly Is bcaW In a:Consavatlon Arse YIN N Histork Distrk�Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: o C2) b Address: otSFf i ��i�c s4 soy�-hy,� relephon.: lI1IZ� ( / 3.0 COMPLETE THIS SECTION FOR WORK IN EAULaNG BUILDINGS ONLY Addition Existing 3 Renovation Number of Stories Renovated Change in Use New Demolition Existing !S-c s Approximate year of Area per floor s construction or renovation n Renovated �S s of existing building 1,260 New i On Skid Des cription p pbon of Proposed Work. �e�Ove T/ s 11k,,•� ii e Mail Permit to: