131 DERBY ST - BPA-07-1045, STRIP/RESIDE BLDG SIDE What is the Current use of theL Building?
Material of Building? C a raocc r&4 It dwelUng6 how many units?--4� __-- '
Will to Building Cahfom+to Law? a 4 Asbestos? r m
Amhftds Name
Address and Phone
Mechanic's Name-Da n 7 u�C r y 1a✓� I
Address and Phone 25 red
ConstnAtion guparviaon License t! 0$9 a S HIC Registration 0
Estimated�s 1�10 PermN Fes Cala+latlon
Permit Fse$ Es*natad Cost X$7f:1000 Residential
- Estlmatad Cost X i11/:1000 Cwmwcla�
An Additional$5.00 is added W an
Administrative charge.
Make an that all flows an property and IegiblY written to avoid delays in pnxessing.
The undersigned does hereby apply far a Building Permit to build to the above stated
specillcatlww. signed under penalty of pwIury
Date 3s a
of
x b C
-� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
VVAST IiN<:iJN 51BEET♦SAUM. MASSACtit.Aa'IS.0191C
O / 'rn:978-745-9395 *FAx:978.74COW
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# _ _ __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 1.50A.
The debris will be transported by:
W-
(name of hauler)
The debris will be disposed of in
(namr of facility)
,�dircsa of fuciiay/ .
,i :atura ti,xnnic app.iuot —\
'ham.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
IdAVM IM WA%4 ar.,atsUW*snot,MM"0stmrrMGlWG
MU WW4$.M a FAX WW469"
werlo W Cmpawdes Imunaa AiNdeft swMarwc
Atanik tall I. dlatrmtedom in""Print Leffbk
City/Sttua2tpa
Are yeet an ampMyr!Cheek mr appropriate Ism
1.131 am a empbydr w6k 4. ❑I as a sward caaumtsr and I
2.�ampbyen 0W asd1w p@r"me}• have bi ed the & �aoO�
I am a eels psageiseor or pertaer. Heed on the etuehed sheaf 1 y ❑amoddibg
ship sm have no mployesa Thee ab4commetent have a ❑D=cWa.
working the me in any capacity. work one coop,insimeaes, g O addttAon
(No workm•Camp UWAs me S. ❑ We an a oorpondoa and id
3.O I homeowner
offA=bow exorcised their l0.0 Eierbicd npdm or additions
an a doing all wall right oteesmpdon per hmaL I I.O Phsmbks mpsW or additions
mya11(No wworkes•comp a. 132.f 10%and we haw no I2 Y>;oof►aFaim
inwnanoe nquirsd.]t employees.Db Work=, I3. Other � fSS
Comp insmanoe ]
-AsrapplieWdds"irast MWWIN 00066UMN Men,rwyarfr..r.d
ftaetwwNwrites etwadiedda"WdlabsdrynedobsaeadtNadir♦tinarli ""itefthtaevee91 , IeAoriraai
rCoeeeedwAreftAYiweaoMitrdWwaddafauatsMrdYwlaadraensefdrW&COOMMaaddrk" w•Nowpaty
�� tAet b prrrt/Eed rrarAassfd nwpawsfen lurnweiJer q eaaploy�aa daAnr b rAe podey assf/o1 sfYle
lnaurana Company Name_ qQ E7M1t )M �i`JAi yJ
Policy 0 or Self--ins.l.ia w &pirstica m l2 I G 7
Job Site Addm __ L2- 2Eaz S/- CityiswwZip 5A
Attack a copy of the worheno eonpesndos pogry daeLnd"pap(Showing ebe pogey Number sad eaplraden date)6
Failure to secure eovenge as required under Sateba 25A of MGL a 152 can lead to the kVOddosof criminal pattalda of a fun up to S UW.00 anNar ons yene impdsonmestr.as well a Civil Penalties Acr
in the form of a STOP WORK ORDER and a e
Invs
of es to f230.00 a daytigsdom of the DU for Afor the violates: Be advised the It copy of this smemm may be forwarded to the Ogg"of
inwnaa Covmge vaitieation.
!do baiting card/j andp the paw and penam"o/perju-7 AM At 1%rned"pevvided above 4 dw and cerrees
Oa S /30 ] of
Phone M 6 /7 02
o,0?eld nle oaljt Do not write In/A&arr4 to be Cowplatd by city or town 04*14
City or Tows: PermlUUeew fl
Issuing Authority(circle ana).
I. Board of Health I-Building Department 1.Ciryltows Clerk 4. Electrical Inspector S.Plumbing Inspector
&Other
Contact Person: o►.__
PUBLIC PROPERTY
DEPARTIM&NT
Wraa t3otlrwurwTnw gnear�3u+uti wwaRsrre ots7o
Tta:MUMS"0 Fite M71P9W
APPLICATION FOR THE REPAIR REMWATrON CONS trntrrCnON ,
DEv[OLMO-M OR CHANGE OF USE OR OCCUpANCy vOR ANY EJrIST G
STRUCTURE OA B m- IN .
1.0 SITE INFORMATION
Lxadon Nsmac _ i--, �rr co u Do s Buildirt¢ `R o
vr
Prop"Address:_e_t-t"1 I % S A o c
S A Z_r �u 'A -( Z cD
Is beefed in c Conservaka Ares YiN Pi eela obwd YM
2.0 OWNERSHIP INFORMATION
2J Owner of Land gr, _554 N c_ co u o
Name: U 2 GL� sT t 6
Addrsaa, l 3 ! P R r3 Y s r Z
tt( A o ( IT 70
T o 'Z
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIM BUILDINGS ONLY
Addition gEyjsVn
3
Renovation Number of Storie
Change in Use 3
Demolition
Z j'm o
Approximate year of Area per floor{sq Renovated
construction Or renovation
of existing building New
Sdd Description of Proposed Work-
y�i;— SrDrNG aF Dkr � FW� � C5615- ) of
®uB LDrNG
-Mail Permit to: - -