18 WHALERS LN - BUILDING INSPECTION What is the current use of the Building? 1.
Materiel of Building? dwelling.t rn units?
-7- —
We the Building Ccnfb"to Law?
yes Asbestos? a —
Architeds Name ( )
Address and Phoneu�C _
LKGI
Mechanle Name Ot 5 f
((S � �+'
Conwtru visors Ucense N O �1 HIC Registration is Addrm and PhoneI (�yO 7
Fee Ca .
Estimated Cost OfPro. y y 0 O Pam-A kulatlort
Permit Fee 5 i Estimated Cost X$7Is1000 Residential
- Estknated Cost X S1 1$1000 Carnmwdal
- - 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�Pssrrn build to the above stated
spec ns ifCatio . Signed under penalty of pedury /� V
Date-64- C5
J
N q,
� ILL A
-
PUBLIC PROPERTY
DEPARTNIE►�TT
Nwraa 130 W�swwc.•icx+sT•
&VXK M.%ssAop:sk-1n 01970
141:M744S"•FAX 97e•740.964
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCLtp�NCy FOR ANY EXISTING
STRUCTURE OR BUILDIN
1.0 SITE INFORMATION "
Location Name: Building;
Prop"Address:-
Properly N bested In a:Cone0018110n Area Y r Hlstat DWIld Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: , �,
Address: ( 56
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN ElaAT1Na BUILDINGS ONLY
Addition Existing oL
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building I New
&ief Description of Proposed A -
WL Work:
O
1ge„N►� s�/JeS c»-� �'C. -Eod-�'�-i.�-f--
— - -- Mail Permit to: C-�, C—
CrrY OF SAI.EM
PUBLIC PROPRERTY
DEPARTMENT
WAYM lm IAaee07bNS&M# a SAISKMA iAC MUU01WO
TM WW4MW As FAsa 09446-IM
WerlrW Compatesador•IamM"M A1Qde t 2wM@wca
Name t - �aw��.
Adr l( � S� �"�•btc�ea y c 9 y �_
cityistala per* —7z5(—&35- vv —tO
An o*a~Check tke approprlaaa beat � ___,�
I. I as a employer Milk 4. 131 an a pared Camrmamr and 1 of J � d1:bm
employee(M ma"pers-dm.}• hay.bina th. , d' •
2.[31 M a Cole pmpdasor or Palmer- Hard or-td Maded dbnL t , 7.
rhip and haw me emplayeee These aw h L
working Nor ma Is say capacity. waken'Comp;meanaa
. st=
(No waken'camp imatt n a 1• ❑ we m a Goepoeador and im 9' 0 adwhas a wd=
regetieaLl otlleem haft Owdeed their l0.[]114 wAd repairs at addttiew
3.[31 am a boussawner doing all wok right daemon pat MOL 11.13 Phmd tng regain or addkiow
my"(No wakemf comp. a 152.11(4X and via have an 12.0 Rdo
teRom
rnatnun ) i swr orft Pb wakecam na 1 13.13
;M"dons Act dwb lead mar da tm err ae reds talon rYalea aekaaala�'
Xems+emeNawbmltObYambeebdeadold"wddydaedteifrelbaatlltaeaarrei�iiimk awe tl�aa tCoaaarwt err alma ab bm d ON"s addidmd dmr dwlee at sat afdr Yietebta esi
waKaararw rd ai.ata�'ese,paw isawnwra
rAar b prrr!!Aq werAas'neepetemdea GsarrweeJbr A4 earpAyeea daAne Ar Aka poft end jab sl#r
insanaee Company Nsn !ft2 � ,,✓( W L/S
Policy tt Or Self-ins.Lint w 0 0 S�3—T(00'�
Expiration Der,_g 0�
Job Site Addre w 12r �4�+ "� ✓i C
Ci JStaa 7* x le`n
Attach A copy of the workers'compeaaatbe potlry datlargd"pap(showing tbm poney member and aspiration daq�
Failure to meM Coverage as raptieed under SeCtfoO 25A of MOL a 112 can Ind m the i derimind fires to 3 f 0.00.00 and/or ory.yeer imprisonment,a wad u civil peaaldp is the farm of a STOP WORK ORDER��Bne
of up to f2S0.00 a day tpiae the violator. Be advised the It copy of this statement may be forwarded to the OBW of
Invmtigelions of the DIA for inwraaa coverage veritTcatioa.
/do hereby'a atPaW and peeaMer olPer/W1'doer At In oraealfOn
! prov!/ef Chow 4 aft aw/comea
S"t 7 v
Phone wF Z�1 (g 3g — vC) (�
0f]leid use onlyt Do net OWN la All area,As beCeerphwtr CAy!or lows opid
City or Tow` PerndNCleeese ay
Issuing authority(circb oae).
I. Board of Health 2. Building Department J.Cltyfrowe Clerk 4. flectricak Inspector S Plumbing Inspector
& Other
Contact Pence•
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
.\1aT?R 126 W ASI ING"i ON S CREET♦SALr V, MA SSA C i II.SE 1-1 S 0I')
'rr.i:978-74 9595 ♦FAX:978-74C-9846
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 ofMGL 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:
--- (name of hauler)
l7ic debris will be disposed of in
(name of facility)
�u l Gym
---_ (addres5 of facility)
----.___si u4turcofperinit.1 iihcant
IaIC