43 GALLOWS HILL RD - BUILDING INSPECTION What is the current use of the Building? la e-
Material of Building? If dwelling.how many units?�—
W it the Building Conform to Law? S Asbestos?
Archileas Name
Address and Phone
MechanicsNams �,�mP nera�k - tn'G�rer
Address and Phone
construction Supervisors License>r HIC Registration S it
Estimated Cost of Pro! Permit Fee CekwWm
Permit Fee i Estimated Coat X$71$1000 Residential
_-- -- -_ itb. _. Estimated Cost XS111s1000CcmnwcW
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 dose hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
XA
Date
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PUBLIC PROPERTY
DEPARTIVIE►NT
►i�mFx6r o�uscwi
1/AYOI 130 WASHIN=m h'mm•W" MASU[HLShTM 01970
Mm.978-745.959S 9 FAx;97b710.MG
APPLICATION FOR TILE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
-- -
Property ss:--- ----- - -- --- ---
U'-;D Ci+��\ow5
Properly Is 1ocaW In a;Conservation Arse YIN Historic DMict YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
�jA.rY`2
Telephone: -ILA S_ cJ�
3.0 COMPLETE THIS SECTION FOR WORK IN "ISTING 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
Bde1 Description of Proposed Work: c
tc�010N
Mail Permit to: i b- "bL4 (-,ro on,,„y rl f�} , l�o� 4eC, Ma 0 1 CQbq
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
K1\11;J;h1.hY I)KISCOIJ.
Me"Y ol, 120 W.XSJ 11'N('TON STREET #SA I F.M. MASSA C I I USL I-IS 01970
Tr.j,:978-745-9595 +F.x-x:978-74C0846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft __'_ -_ 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:
(name of hailer)
The debris will be disposed of in
(name of fa"ity)
(address of facility)
S1
(late
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
rnsaerra,r naocou
�f A1Oa Ito atiomeerMsrevm.
%.M&%MasusarrsotWo
Tot-M745-"" a Ft x:9W40.9"
Worken' Compensation Insurance Affidavit: Bnilders/ContnctonMeetr{danw?huoben
Aunlicant Informado\ 1a1 .e.oa e Utility
Name(&wi 1: TN1
Addy w:— 117)14 (=c o o rs I yl S4
City/StUe0P: _ 1A� 9E-ak Phone 0
Are you act employer?Check the appropriate boss
1. I am a employer with ( Q 4. Q 1 am a seaeml connector and I Type of proles(ngatred):
employees(iWl and/or pamd=).• have hired the=&coatractan 6. ❑New construction
2.0 I am a sole proprietor or p.rmec- listed on she at4ched sheaf,t 7. OR ling
ship and have no employees These ❑Demolition
working for me�capacity. .�thaw 8.
(No workers'comp.huevanee S. Owe are a corporation and its 9. 0 ling addition
requited] officer haw exercised their 10.0 Eleetricei mpaas or addidena
3.0 I am a homeowner doing all work right of axampdon per MOL 11.0 Plumbing repetin or additions
myself.(No workers'comp. a 152,11(41 and we have no 12.[3 Roof repairs
insurance required,]t employees.(No worker' 13.0 Other comp io=="required)
fAnv wP11CW mat Climb box et meat dui au am the swoon too.shewdae reek wag k�a
I Polity
Nmro.m who amde mi stadrva they as ddy d week and ma tone ow" ate amdt i e�drt y tconuacmn and tAnk We boa must seecW r sd"wA shed showtee er she of m. Wa"°bng'0Ck
s d 6*waam eomv FORM bsawasd s.
lam an omployar that/sprovhlhtj works"'compenaadon b awraweejor cry employees. Below is the lejorma" paltry aw/Jo1 dte
Insurance Company Name: N I n� l
Policy#or Self-ins.Lie.a Expiration
Job Site Address: Ci is
Attack a copy of tin worin'compensation h tata2tp.
Pe Policy deelaradoa page(showing the piney number and expiration date).
Failure m secure coverage as required under Section 25A of MGL a. 152 can lead to the
fire up to$1.500.00 and/or one-year imprisonment,as wen as civil imposition of criminal penalties of a
of up to$250.00 a day against the violator. Be advised that s copy o�u statement the
form
may be forof a warded W to K ORDER
of
a fine
Investigations of the DIA for insurance coverage verificuioe
l do hereby cerdo wider the pains aid penalties ojper/wry that rho iwjormadow provided above is mwe and correct
11 en
Da
Phone 411
offleW use only, Do not writs 1a this area to be coatpletd by c4 or town oJJ&laL
City or Town: Permlt/Ueesss N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person:
Plane M: