BPA-2007-916 2ND FL BATH What is the current use of the Building?-
Material of Building? 0 Oct If dwelling. how many units?_ j
Will the Building Conform to Law? n Asbestos?
ArchRed's Name
Address and Phone 11 l 1
Mechanic's Nams �
�3333
Address and Ph
one
�2Ho- 1't-ex�. ..-i- Danv-.rs i- 71
Constriction Supervisors License# 6-13 6-75 HIC Registration# 103(pl
Estimated Cost of Project Sd b Permit Fee Calculation
Permit Fee$9_ Estimated Cost X$7/51000 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 X /a Y
Date p U
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CITY OF SALEM
PUBLIC PROPRERTY
a a -7 DEPARTMENT
K I MW ALEY')KISCOIJ.
NIAYCIR 120 WASHINGTONSrREET *SALI-M, MASSACHUSLY[SQ1971-
Tri.:978-745-9595 +FAX:978-74C,9846
Construction Debris Disposal Affidavit
(required for all demolition mid 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:
hauler)
of I er)
The debris will be disposed of in
b
..........
(name of facility)
(address of facility)
—Agf�iatu—,—c of permit applicant
�Oj
CTI•Y OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
awatearav atacots.
MAYOR
tMVAMMTDPISTMT.5AUK rtJWM0lW0
40.
Woritera' Compenaadn Imnraace AfHdav(f: BaUdaWC ntraeto
A Informatfog
leeMe)aaa/Plombers
Address: 9 h St
City/State2ip: cu1YUXS I tr Phone#:_
An you!!!:it
pleyer?Check the APPeoPriste boss
1� I aloyer with -3 4. ❑ I am a&mad contractor and I Type of pe)�(regmlrsd):
2.❑ Iemployeft(!W1 and/or paeFtime).• lurro hind the sub contractors fi ❑New eaaatructioq
Proprietor or P�►or listed the attached sheet t 7�gang
shive no employees These have g,
worme in a�capacity, workers•COMP,ins rear& ❑Demolitieureqrs'comp iaeursnca s. Q We am a corporation and its 9' p wing addition
3. ] officers have norclsed their 10•Q Electrical repairs or additions
❑ eowner doing all work right of mtemPtioa per MOL 11.mys workms•comp o 1s2,�1(4�and wt have no p Plumbing�n or addidomint�d•)temployees.[No workers• 12.p Roof repairscoenp�ionnanca required.) 13.Q Other'fir arPikaeb boa NI mar aka IW out dr metW blow*&%•a Ihrirwer�•
t Heerowams Who mbmk dik d5devlt a entme d y ma dob g aore&ad d"No auWdMaefto
Pdlar iebratanaa
rcoeaaemro this drat We bon mom amwhad a ad WWW them AM%the Mona of ibe td&*wor a eew a�Edwlt iadleatbq amL
1 an as em pkYds that is , �aaadas and te.t wodtm Monti Pay khrmaeea.
lajorwadosa P^st�idGrJ reorAera cowpetsrados intonatejot aq'ewPlayeea SCAM it the
Poda7 an/Jo1 sEtr
Insurance Company Name:
Policy_#or Self-ins.Lie.N; .3^Q Z, Np d—i
Expiration Date 0
Job Site Address:_ 83 4-0 w S f
Attach a copy of the workers'coon asador City/S4WZip'
Pa polity decleratlon Pap(showing the Potley number and ex
Failure to secure coverage as required under section 25A of MGL e. 152 can lead to the' Ppoessiti }
foe up to 31,500.00 and/or one imprisorunent,as well sec civil mP�tion°f criminal penalties of a
of up to f250.00 a d• a pens in the form of a STOP WORK ORDER and a flue
Y against the violator. Be advised that a copy of dtis statement may be forwarded to due Office of
InvestigadOna of due DIA for insuraece coverage verification
/do AereAp eerdt,under tAe pains and penaA4r ofpedu,dar ttre In o
j t'tsados provided trsa anlcarrsca
1114 �1 -3333
O.&W use only. Do nu Wks`1s tA/s area,to be completed by c4 or tows o,(Jleh d
City or Town:
Permlt/Lleease N
Issuing Authority(circle one):
1. Board of Health 2. Budding Department 3.Cityfrown Clerk 4. Electrical Inspector S.Plumbing Inspector
Other
Contact Person
Phone*
Information and Instructions theirs
H husctte General Laws chapter 152 rc4auaa all t mployas to P1Ovids worlco f compounder a fy end of hire.,
pursuant m dun statum.an srpbyen is defined as 0...every person is the service of anodtar under any
at implied.ad or wnum* _or_
express assoekation.corporation or odor legal cn*.a an or the
An taipfnWr is defined as an individual.parmash* va of a deceaed MP lYwever the
of the foregoing engaged in ajoint eotaPtiss,and atcladittg��"Is""ft.
receiver or ttvaw of an mdivi"PaMerah*aaaeiatinn err others� or the ooaaPsat of the
owner of s dwelling boar having not mess than thus=apaineab or , an such daell3ni hoese
dwelling house of amthst who em rtro a P�� wch emPloymer be wed to be as empbyr
or on the grounds or building apPaM°aat Y ised Ilcevia8 seamy a "withhold the kuoaaee or
state err fen any
that evarY waaltll
also states the cemtmsa
151.;1SC(� a<b eeaatree3 bdWlap
V
MGt.ehsPeR coverage rMdrec
Kann,of s.hae not or paw b as��evidame o f eosp8ana wUt tM Insuof- u�� shill
spp ally,MCd.tP 2SC(n agates dpubli�ung eptssble evidence of compliance with the inmr
VAC my its po
req
enter into anyof his h eve presentedm the contracting aatbarn7r-»
Wremms
APplleaab checking the boxes that apply ta'Yaur situation if
Please fill out theca s �ermosion own* r��phone a "(��no s)of
od►a dun the
�e�• Liability Costpivur(LLP of Lisuted Liability employees
member wanumat paON%we not required m carry wakas�moos m Waursom � of Industrial
empleyeM a Pow,Is Be advised dot this affidavit tinny be submitted
of knnsasca coverage• Abe be son b aft aril data the a®davlt The aPfldavit should
Accidents of
tar�asatiO° application for the permit of license is being requested.tact the DaParssaot
be rehstud m the city b town that the app the law of kt you an regnired m obtain s workers'
I ds1 Aeeidesb. Should you have any quatiosa regarding
compensation 11O°PolmY•pkar salt the DaPs� namba listed below. Self-Wpuvd couWGW a should onto dicer
Htmse aumbar°n mO
UnL
self-
city or Town Ofgd1111 provided a space at the bottom
Please be sure that the affidavit is complete and printed legibly. The Des has
to contact You re
of the affidavit for you to fill out in the event the Office of Isveatigadoaa has m c you regarding adiag the a applicant
ense numbs which will be used as a reference number. In additio4 an aPPh
Please be are to fill in permit/ltc in nay given year,need only submit one affidavit indicating current
that asust subunit multi Pam)censeand applications.Job Site in my �'chn acpwp' st should write"all loaders in---(City or
Palms'm{armasos( bent offleially stahnnemped or masked by the city or rows racy be provided m the
town)."A copy of the affidavit that hasPaULb or licenses. A'now af,'&vie rmist be tilled nut each
applies%y that a valid affidavit is oa file for
hearse or�t not related to any a eia1 venture
year.Where a�how owner at citizaa is obtainiog u NOT required m camPlemb this affidavit
(i.e. a dog license err permit m burn leaves eocJ said porno.
for your cooperation and should you have any questions.
The Office of invesd pttioas would like to thanit you in advance
please do ow hesitate to give us a ca1L
The DePartmcat'a address.k1ePhO0Q 'IU COMMnwalth of Mmachusetri
Dep"Weat of b&sMv A=dentg. TM
ofa d Iavadpdong
600 wahin8 M Stag
Boston MA 02111
TeL a 617-727-49M Cd 406 of 1-877-MASSAFB
Fur 0 617-727-7749
S .IM dig
Lie viscd 5-26-0 1tIVYViI $ov/
CITY OF SSAMNI -
PUBLIC PROPERTY
DEPARTMEINT
IQ.%ftW-RLEV ORW:ULL
MAym 120 WASHINGWW MEET•SAL"k,%L%ZA0iLU.-r S 01970
TM-979-74S.95"•PAM 976740.9646
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
? STRUCTURE OR BUILDING
rI.OSMITEINFORIMATION4
ON a n 453 6 Or u 64- Building:
:
ted in a;Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: �3 r3arg l ow �-
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation ✓ Number of Stories Renovated
Change in Use D' New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: R1,,M0 t?L bal�,<Uty ,
---_--- - _ --Mail Permit to: _ __ —