13 BARTON SQUARE - BPA-2002-893 ABATE VIOLATION What is the current use of the Building?
Material of Building? �������� if dwelling,how many units?�
Win the Building Conform to Law? Asbestos? �O
Archited's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# 7 HIC Registration# /3 7Z/
Estimated Cost of Project S 20-020 ° Permit Fee Cak:ulation
Permit Fee$ Z S Estimated Cost X$71$1000 Residential
- -- - - -- - _- - - - - Estimated CostX$i V$1000 Commercial—
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the
ttthhe above stated
specifications. Signed under penalty of perjury
Date
N
ZIA
� u Q •�M � o
CIW OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Mrtroa
u0wasataeroNStassr0s Ln;MA%MMXSBM01970
T IL 97L745.9593 a Foxe M740.9W
Worker' Compensation Insurance AfAdavit: BuffilarlContractOnMecl claux/Plumben
AppOcant Information a ts.t.e r �
Name( ):V I C l-lo /
Address:— 17 LzlTtk <,,
City/statemp:4LL ..LZW6 0 01 0 p},one#
Are you o emptoyor?Cheek&a appropriate boss
1.❑ I am a employer with 4. ❑ 1 am It gmaml 0011twtor and IFC3
(r1employe"(ju and/or pa td=).e have hired the sobcontractow ruction
2.® I am a sole proprietor or Wtton, Hued an the attached shear,t gship and have no employee. These sob-comaesom haw wonting for me in any capacity. workers'comp,We mrance[No workers'comp.insurance 3. ❑ We ere a cmpontion and its dition
m ] Of&m have exercised their lo•[]mectriicai rapsim or additioma
3.[] 1 am a homeowner doing all work right of
myself (No workers'comp. a 152,11(4 �we haavve no 11.Q mina or sddirlena
�Ze required.]r employees.(No workers—
comp ioaaaoce requited.) 13.0 Other
�AAy wntte m that ahedm era al mud tiro t01 ma roe ssetloa bdow shsadea o*wod ma'su0�samdaa➢o�y ie6tmattaa
stameovmn.fia submit*it aladnit odleatlas dmy sm dd ag d eedt and bin aunlde
tCaastrea0me mhst eaatraetom mot abxk dds boa mum esar;had m sdditlaml dwt bwwia eA sfadtrY tutL
m6oeiaadmamofthe �
and mhslr eats. mop poesy iabtmstlaa.
,ran an emp/oyar that bprovlding workers'compensedom ruaraace of
In/ormadoa I l my CNPOW" Re/aw it the po ft andlob slq
Insurance Company Name
Policy tl or Self-ins.Lic M
Expiration Data:
Job Site Addreac
City/S4te/Lip:
Attach•copy of the workers'eompeasatbn policy declaration page(showing the faihmm w serum covers u � Po�7 amber and expiration dab)`
as required under Section 25A of MOL c. 152 can lead to the imposition of criminal
penalties
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the f MOM of a STOP f
of up to OM a day against the vioWw. Be advised that a copy of this statement maybe forwarded to the Office WORK ORDER a
o tine
Investigations of the DIA for insurance Coverage verificationof
/do hereby ceragjr andei tke aGsr and pea ojperJary that the o in/
rmadoa provi0il above is trw and correct
n 1 ZG O 7
PhoneN: �J off —3lq—Za
0,07ew use only, Do not write In this are;to be complete/by city ar town of)lelaL
City or?own: Permillueass 0
Issuing Authority(circle one):
1. Board of Health 2. Building Departmtet 3.Clty/Town Clerk 6.Other 4.Electrical inspector S.Plumbing Inspector
Contact Person: Phone M•
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:KAMEHt.FY Imuc ;l.t.
170 WASrttX(iTONSTREET ♦ SALFM, h1ASSA(:iR,SIa1S 0197'
TEt 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
1 11, S 150A.
The debris will be transported by:
(name of hauler)
I'hc debris will be disposed of in
(name of facility)
(address of facility)
t
ii
Vlaturc of permit applicant
date
.kl;ri t.a:dnc
C QF LEA a/ �� �a/°� ?E is
,! ,
PUBLIC PROPERTY c_ �1' 75 31 y z �33
DEPARTMEINT
Ki.%01FJLLFY DRWXX
MAYOR 120 WwUNGTM hMEKT• '�nttati M.ltSAoll;ilTtS 01970
111:970-745-9595 0 FNc 97b740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUM111DUG
1.0 SITE INFORMATION
Location Nam: /3 Building:
Property Address----- — ----- - ---- --- - --- —
1
Property is located in a;Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: G
Address: v�
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
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 New
136-1 Description ofProposed Work: ,,+ I
'j1102� A•4' c V' a/Q�! ratios
--------Mail Permit to: ---- --