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0007 BEACH AVENUE - BPA What is the current use of the Building? Material of Building? If dwelling,how many unfts?__--- Va the Building Confom►to Law? Asbestos? Archited's Name n �� Address and Phone f 5 TM�In br Medhsnie's Nameb Address and Photo Q l0 Og� HIC Registratbn fi /0 2Z u 2 Construction supervisors License Estimated s :.Z .? Permit Fee Caiwlatbn Permit Fee S Estimated Cost X S71$1000 Residential Estimated Cost X Si 11S1000 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'pmessing• hereby apply The undersigned does ply fo►a Building Permit to build to the above stated specftadons. Signed under penalty of perjury X Date 1 S" °7 ft CJ 06 N e � yu r s y r 4 1 Cr 1 OL' PUBLIC PROPERTY DEPARnI&NT uwraa IWWA""OW rair• &MYx WASSACI&SlIZs 01970 nL 97{.749•MS•F.x 97L740.gW APPLICATION FOR THE REPAIR. RENOVATION CON TRUCTION DEMOLITION, OR CHANGE OP US* O003ZA [ry FOR ANY FMIM STRUCTL�� OR BUIL.DIN 1.0 SITE INFORMATION Location Name QD t bo.d S410� Building: Properly Address:- ._ 7 tD 4¢ e L- - , Property is located In a:Conservation Area Y/N Hl tMt 01skid Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ` Name: 9(is, " S �v Address: 7 rgsAc k S.) Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISIINQ BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (50 Renovated construction or renovation Of existing building I New &ief Description of Proposed Work: C L f `�/F l0'C¢y� .. �lLL�d�( t.�Dc7W S�^"�ll� 4 ^'9•� c�C�t_ �G F�'d�d� ✓�..� Y�.�w �iaSL..� -- -- Mail Permit to: R 1 (3���c Z Qd TeL ksbLAi a Alvass CITY OF SALEM PUBLIC PROPRERTY q `) DEPARTMENT MAVM 120 V.SHVQnsrM S,aesr o UL M4 TIr 01WO TEL'9W45'9M o FAX M710.9tt6 Worken' Compensation Insaranca Affidavit: RWden/Con Aand ant Informatiot w,ra.t,.it EAdbly Nart1G( Address: CitvStatai ip: �i ks� e•� Ytirr. 0/�7 L Phone i1• tP 17— 71 9— 2Z L3 An you We aspleyert Check the appropriate best 1.0 1 an a employer will `3 4. 01 am a scream contactor and I TYPa e<Pre]ect(+e9niree employers(M"or pat-timely have hired the 6• ❑Naw construction 2.0 1 as a sole proprietor,or partner. lined on the attached sheet t 7. 0 8amodeling ship and have so employees Thee have t. 0 Demoutle a working for me in ay capacity wodron'comp.insi mes. [No workers'comp,iowraaee 3. 0 We an a coepentlon and its 9' H1117ding addition mquhv&I of cars have exercised their 10.0 Eloc&W repairs or addMons 3.0 1 am a homeowner doing all work right of mrampdoo per MOL 11.0 Piumbiag reps at addidene eying No worksro'comp. c. 152.11(41 and we have no insurse required.)t employees.[No workers' 12.0 Raotrepain camp insurance requited,] 13.0 Other 'HHoomeawme win n6mbOrbsd&WA.0deraartheoseneah6wohowlgt6rrawtke' Detiel,bbotaatba tCoatteteeq the chit eW ttoa mat ate it�tlaaeil, d weds and era tin ad6 oamaaen art&60 a me,ala6vtr bdkohr MML 6ndet d tee ors.robeo.a.r+rn d err wartoe'eeq,Peary fakrtuorea Ian an anpfoyor that b provians woraws'comp mews/nsyroweefor my e leformodas. ' arployrea Below b ire poUey aafJol sAtr Insurance Company Name: C,24 W M"/1� Policy N or SeWins.Lie 0.- w C-7 9-7 ir6 i 9 Expiration Due: S'2't.�� Job Site Addrere: 7 25e'+e4 A Ciry/SWaq*. SAI� 11?4 Attach a copy of the workers'compesaadon policy declare pea(sk*wWgthe Failure m secure covtsa Pew member and apind@n date). fine up to$1,secure 00 and/or one s under Section 25A of MGL e. 152 can lead to the imporiCon of criminal penalty of a of up to 5250.00 s der a Y � 0 u wen u civil penalpa in the form of a STOP WORK ORDER and a if= Investigations t Y i(�do viol. Be advised that a copy of thin statement may be forwarded to the Of @ of gallons of the DIA for insurance coverage vaif C360 . I do hereby cardp mndgr A#paGrr an/prea/du oJPrr/yry that the/n forsrat/ow provlJil chow u arre an/corred Siroature: CD17-- 7/ 9 - 7-z23 Qpfeiai use onig Do not write In rbb errs,to be Cosrpletral by Ciry or town oQfele( City or Tower Permlt(Ucense N Issuing Authority(circle one): I. Board of Halt► 1.Building Department 3.City/rows Clerk 4. Electrical Inspector S.Plumbing Inspector 6. Other Contact Persos Phone p• CITY OF SALEM 01�' PUBLIC PROPRERTY DEPARTMENT "AMI-R I.ET!�K isi.011. \LiSOR 120 WAi1tIXbi0NSfRLET ♦SALI:M. NtASSM: it.SLI IS'.1L97;. 'Trt:978.745-9595 •FAX:978-74G9846 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 ofMGL c 40, S 54; Building Permit # ____-___ is issued with the condition that the debris resulting from this work sball 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) the debris will be disposed of in "g -r 7(Z,A-1I54W (name of facility) t� dress of facility) iigilature' 7 of pentilitapplicant /) — © 7 date