23 BENGAL LN - BPA-2007-2013 REMODEL BATH What is the current use of the Building? If dwelling,how many units?-- —
Material of Bum? Asbestos?
Will the Building Conform to Law? J I 6A
ArchitedsName
Address and Phone
Mechanic's Name %'zn•s ""`"'r
Address and Phone O
Registration 1
Canso Supervisors License 0 4&0 HIC
Estimated Cod °lads 3 S Permit Fee Calc
E ulation
stimated Cost X$71$1000 Residential
Permit Fee=
Estlmated Cost X i111i1006 Commercial----- _
_ - An Additional$5.00 is added as an
Administrative charge.
Maio sure that all fields are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building pwmit to build tq,the above stated
specifications. Signed under penatiy of perjury /�
Date " a
N
`? a a0
am 'F o 0
_ a C7
EIT Y"OFrgAIEXI
PUBLIC PROPERTY
DEPARTMENT
�a+wcxsr ouscuu. /C.CYi� V
NAwa
130 WASUNG"b17 0 3,uby p shTM 01970
11-r6-743-9S9S•FAX 97L740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CRANE OF USE OR OCCUPANCY FOR , EXIST<ri
STRUCTURE OR BUILDMG
1.0 SITE INFORMATION
Location Name: SuddkV
Property _
Properly Is located In a;COnwnlatlon Area YIN Hlstarlc DW4 Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Nam: r^ G,
Address:
514 LLAA
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN 71stones
BUILDINGS ONLY
Addition
Renovation Number d
Change in Use EE Demolition Approximate year of Area per flodconstruction or renovation of existing building
Brief Description of Proposed Work:
Mail Permit to• �oHaro •r MAnrso�c ��, A �„� ��
O
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:aurrKi.r.r I)KISCOu.
120 WAM HNG.I ON S CREET •SALI:%1.MASSACi I L SL rf S 01)IC
Trt:978-745-)595 •FAX:978-743-9846
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 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:
((ttof hauler)
Fhe debris will be disposed of
in
(mmne of facility)
� 1�Sdres; of'lacilit;')
hl:alul i permil aappiicaot
date — —
CYTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
WAVaa u0 VASt0=M Stnsatr a UUK MAMA0Mff s01970
71114 97e.7et 4M a FA*97Ne69W
Workm'Compeaudon Iuoranm Afddav* BWWftWCoa
A
Name 1
Addmoo ct•,. e_ y
City/Stato/Zip Ws o�g 1P6one tY 7 7�5�3 ?3 `jGt(5 Are ysa as staplsgw?Check the Appropriate. _
1.❑ 1=a employer with 4. Lf i em a read centandor and I �
aapbyas(1hd amd/ar patbdms}e baw hived the 6 0 Naw caattrmedaa
2.❑ 1 am a stab proPtletor or .patmeo. listed an the attached ebea,: 7. p Remodelies
Ship and have no employees These aa000aaetms havo L ❑Demolidaa
working for ma In sir capacity. waekm.'camp.inamaaa.
(No wadoms'camp ioasman 3. ❑ we am a eospradon sad is 9. ❑Ong eddhim
3.❑ 1 4IM") wiener oAlean bava sawocind their lo.0 Elecuieal regain a addidoos
doing aR wock right of erempdoa per MOL l l.0 n=bh g mpaka at eddidow
myeslL(No workms'comp o. 132.f 1(4),cod we have no 12.[]Roof tepaim
rtm u )t aopleyeea END worketa'oa 13.0 Othr
mp ime maoce taedri d
;Any ap OOMasdWbbentat=0aloe All asasestla6d—mA ebgad►wattaa'
RearmaatwaaaitarraldMtaYodrra.Ywdeitiwdtm/aMIdnow Y�note&*tCeeewae data desk ab ber eea iaeebd as addidood dm dewlee ae sass sae ��eaeL o/ails watraa•aq,parer batrs�ttea.
la
m le rAat bprovld6tB worAas'eewpawrioe a forV ealls ym Behr b tAe pebkp a+eet/e(r Stttt
Irauraoce Company Name. q Policy N at Self-ins.Lic.i �yd1_ Oz7b7J/ y F.xpirada te•o Da �
Job Sire Addreu .2 / e14 r4.e d�y.� Ciry/Shs/Zip
Attach a copy of the worltre'aopewdoa policy declarlden Pap(Showing the pogey number aid exptradoa dap)6
Fsihue to secum cowtap as requited under Section 23A of MGL o. 132 can lead w the
fine up to 31,300.00 andlr an♦ ac' o f&STOP
Wss RjE O l peat of a
Y unprisonmetd;>r well es civil petuldes in the form of a STOP WORK ORDER sad a Rae of up to$230.00 a day agaimat the viower. Be advised that a copy of this mtement may be forwarded to the Of it Investigations of the DIA for insurance covasp vai&&tiod
/do hereby carat soda tAe am/PewaMn ojped AM Am tM Jn/ersmtbw preWd abort b trw ea/csrrmm
tj-�12- 0
CIL
OJf eld use 04 De not wdl4 in tAb ores,to be cospbrd by 4 or totem q(jfeial
City or Tows: Permit/Lleease N
Issuing Authority(circle one):
1. Board of Health 2.Building Department J.Citytrown Clerk 4. Hlectrtcal taspactor I Plumbing Inspector
& Other
Contact Person'
Phone N:_
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only
Registratfon before the expiration date. If found return to:
�_118509 Board'of Building Regulations and Standards
Expiration 329/2009 Tr# 130819 One Ashburton Place Ron 1301
"TYPO: D'BA Boston,Ma.02108 I
R.J.CONSTRUCTION F �
RICHARD MADIS ;�:L"Y
3 MADISON AVE
GROVELAND,MA 01834
-- _. _ - Administrator Not valid without signature '
"100mMtd)N...... 4 a�+�lN[([OAar,�tauB 6�
,t - BOARD OF BUILDING REGULATIONS,
dense: CONSTRUCTION.SUPERVISOR '
" T
t lumber CSC 030000` -
Irtrthdate 07lSa/1948
xptres 67l21/200T Tr.no: 3742.0
Restricted t 0 Jj S
RICH
ARD J- MADISOI 4.
c
3 MADISON AVE
" GROVELAND, MA 01834
ggyy s � '� Commissioner'