99-103 WASHINGTON ST - BUILDING INSPECTION What is the current us f thV ildingT
Material at Building? if dwelling.how many units?
WIM 111e Building Con
Law? Asbestos? '
Architect's NameAg��
Address and MOM �
Mechanles Nam
Addrm and Phone HIC Registration S
Construction Supervisors License M
Estimated Cost of Project: Permit Fee Cala,latlon
7 o Estimated Cost X$71$1000 Residential
permit Fee i
-- - - Estimated Coat X it 11S10oO Commwcia4--—
An Additional $5.00 Is added as an
Administrable 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 Penury
Date_
rs
15
C,5
o s �
a
a o
a �7
a
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tcatsmant muscat
MAVoa 120.A 4dV6TON117raT•satn6ldAfeapa�Rt01970
T!L•9W45-"%.Rue WW469w
Workwas Compensation Insurance Affidavit: BuUdmXa
Anadnat Ishrmadom Plead hint r.etas.
AddKa,:7L% ,flees s4-
c,eyisawztp:(' ,�/�rJ 1�140/R;7� Phone
Ars row_a■Pieyrt Cheek ties appropriate her
1. as a employer wick 4. ❑ 1 sm a general eeoaeeter soil Type m
employee.(Ana and/or psrs- a4e have hired do , 6. ❑1New cones
2.❑ 1 ss a sale proprietor or Palms. listed an the saseb d shoft t 7. ❑Remodeling
ship,and have on employaea These wb000traatom have L p I7esolitlan
working for me In new Capacity. workers'camp insurance, g, ❑gym addttian
(No waekma'comp:insurer" s. ❑ Ws ate a corporation and its
p 3.�] I homeowner otlloers have Mara ad their or 10.0 Electrical repairs additions
doing as work right of esamptioa per moL 11.0 PhtmbIng rapairs er addit(oos
myself:[No workers'comp, e. 152.j I ft and we have no 12.[:]
Mauna regtaired]t employNL Din workers' 13
camp temum requbot)
t ePPWard.AndsYouhmoterresamitsreenaatdewdYMgetetr.a,es,p
HmrotaerYa ratty nY�YrdletYr IYgr sw delat ee teak asd deer YYs ateW e. mPoftaderYkhnm"aladwe irttatYtg nor►rCeee.Mea sir drek side led mot itsoW.sddYloeal Act Is*A 00010 ef`o erYreaasaet./arir wart.,'eoq,PsMW tdnnindes.
rlo UYtrb PrevrBrrg waAeq'eo.Penssdon LuanteeJor nq/a//wPkYaes B.Aer b rAaoeNep e+rfJoa sdtr
Insurance Company Name:
Policy 0 or Self-ins.Lie.
1F Eapintion Dora
Job Site Address:�/ ��I(� (,f/ft',h i^ 2��c _C;ry�settt�zip:
Attack a copy of the workaa'compensation policy declaration pap(showing the policy number sad
Failure to secure coven as .sptratlon date}
p required wader Section IJA of MOL o I s2 can lead to the imposition of aiminal penalties of a
fine up to g"W'00 and/or one-year impsea isonmook as wall as civil penalties is the form of a STOP WORK ORDER and a Ana of up to S230.00 a day against the viokW. Be advised that a copy of this spament may be forwarded to the Otlics of Investigations of the DIA for ksman covemp vaiAesdoa
/Jo/unby cot ii1p As andPeea/des a/Per/orp tAer At In/ormadow pro vles alo Is ow end card
Da �/ LO
Phone M
F
aa/lt 00 not wrirte In tAlt area,to be coselk"by Puy a nest gafe/e(
n: Permlt/Lleeasshority(circle one):
Healtb 2.BuiWing Department 1.Cltyrrown Clerk 4. Electrical laspector S.Plumbing Inspector
ti Other
Contact Person Phone At ___
!° CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�nu,r.n Cr.i !+nna;u.
\1:,st 1; 120 WAi11ING ONSCREET •SALCV,\t.UiAC1LL. LflS 0197:
TE1:978-743 9595 ♦ F.+x:978-74G98+6
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 fl .___,__ 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
l 11, S 150A.
The debris will be transported by:
[name of hauler)
fhe debris will be disposed of in
r
(name of cil ty)
Inddrcss of facility) .
-_ �i uaturc of pan la applicant
- `Q 7 ---
;atl'
i
� �' �/(
r /
> >o
7
�� S o
��SS
} -
—� EIT�OF&XLM
PUBLIC PROPERTY
DEPART INI&NT
N'..%OWALSV ORWAI L
Ya 130 WAQUNG"Sr&W#SAWK MASSAdIl:SlllS 01970
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPAn1it`y FOR ANY MSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name:127fflll Building;
Properly in a:Cwm mtlon Area Y Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Tebphone:
3.0 COMPLETE THIS SECTION FOR WORK IN E�USIINLi BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of I
�6� Area per floor(so Renovated
construction or renovation
of existing building New
and Description of Proposed Work:
eel
Mail Permit to: -�
a1�3�