29 GARDNER ST - BUILDING INSPECTION • PUBLIC PROPERTY
DEPARTMEINT
Kj.%fiW-1LEV 13RMWLL
MAYOR 120 WAvariarM TMEEr•SALU MAssnriLst-rts 01970
TM,978-745-MS*RAX 976-740-9646
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
F
FORMATION
Building:
dress:
ag �A2a�r�e(Z
Properly is located in a; Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2A Owner of Land _
Name: 1 p
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING 13UILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation New
of existing building
Brief Description of Proposed Work:
Mail Permit to:
r
What is the current use of the Building? AVVV-k2
Material of Building? 0 f�7q� If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone )
Mechanic's Name
Address and Phoned L brr �tti��.�l( a • Q1�3�
Construction Supervisors License# 12 1�6 HIC Registration#
Estimated Cost )-Soo Permit Fee Calculation
Permit Fee S Estimated Cost X$7/51000 Residential
Estimated Cost X$11/$1000 Commercial
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 does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X �ell I,
Date 4
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--- -- - F — -- -- -
CITY OF SALEM
PUBLIC PROPRERT'Y
DEPARTwNTa
KWaTRU MDsuscort
MAYM
t20 VA*mrcroW ST"U a UUK MASACW-U is 01970
TEL 97L743.9595 •FAX 9W40.9W6
Workens Compensadon Insurance Afffdavit: gltilde WContmctGrjMeea{danW7jM
A eh
Q
Name a usineworvoiadayT�):
Ad&ess
Citylstatemp:_
An you to emphsyer7 Check the sppre"ta Was
I-1p I am a employer with 4. p I aM a Seurat contractor and I Typo or Projeft( .
I amasole Pro and/or pP -dme).• have hired the ❑sub-eontracten 6. New construction
2. am employe"(Ihn aemr a armee• listed on the ansched sheaf,t 7. p Remodeling
ship and hm no employs" These tole oontraT tors have 8.
working far me in any capacity. workers'comp,insurance. ❑Demolition
(No workers'comp,insurance 5. p We am a corporation and its 9. p Building addition
required,) offieaes have axwcued than, 10.0 Electrical repairs or additions
3.[31 myself
a homeowner do wont right,41( we
haw no 1 l.p Ptumbina repan or additiorn
myxli[No workers' e. 13
)' 12.[3 Rooftepairs
insurance mgnired]t employee.[No workers, 13. k r`e.�a,�17 .
dW_ COMP.insurance required] p Other L2f,<
t H r m who mearB box eifAdnte wo�eu as�hr redo bdoa r=k md,their ra�t�a•eoe�Poft whnowloa.
rConeaaaart Thw Ann d&boa mot mode a�shm dolv%b Gang ad Thad hid aTTeddr eaonaran cant Whelk.awn afaderk W0601108 MM16
a Tb♦aura of Thu ad
hag watbwd•Gamµ Donor
I ass an employer dYat G prov/dhrs worhen'rostpeasadoe hrrursee� er
lnjoraraaloa j my ratployraa. Below 4 thrPoNC7 on//ol.sfti
Insurance Company Name:_I V c76\�d 6 (�v V-)OA� .,
Policy N or Self-ins.Lie.N
// n Expiration Dam:
Job Site Address: 'b A\���Q 1 J
Attack a copy of the workers•compensation Ciry/State/Zip
Pe policy declaration page(showing the policy number and espintlon dTtm�Failure w secure coverage ad required under Section 25A of MGL a. 152 can lad to the imposition of criminal Peaatda of a
fine up to S1,500.00 and/or one-year kVrisonMem•as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for Wauraoce coverage verification.
/do hereby certi/y ender tht pales an pefiaid"ojpsr*7 that the injorsrodow provided above 4 trwr oral correct
v
offlc f use ORIA Do not wrGe IA 1h4 onto,to be compkied by a tp or tows gQ7eja4
City or Town: PermitiLleense N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.CttytTOwa Clark 4. Electrical Inspector S.Plumbing inspector
6.Other
Contact Person:
Phone N
Information and Instrtictions fa >r�h>
Maasachtmxtm General Laws chapter
defined as awerY P n requires an employco;b'n�e servtea provido r of anat�1II any coavad of vita.
Pursuant to this omens.an ewp&Yn "
expeess at implied oral of`"Rtums'" or any two a mow
aasociaaoe.coopeatien or other legal entity.ssed
An esproye+is defined "as isdividuai.par�P���� veer of a dI ampl d employer.Ho�m�
of the foregoing engaged in a jams attocktks or other leV1 entity,employing�PIOy
receiver err Wastes of as individual,paronashuP and who resides therein,or the occupant d the
ownat of a trusto g boos havht4 not maw than tbtrs wotetuctift er�We&on web derailing hates
dwelling bons tx building aPP �u obese not b0n�of such emp be deemed to be as empbyw.O
or on the Vounds also states that"ev�r7 stab sr local tleeaobag avocy shag withhold tM busaete or
MGL chapter IS2,1�<� a verbs is err b eeaat age
bundlugs 1.tie eowmoswaalti for say
ireV
res owal of a tlestua or ptu>•It b° Ala avWana et eompWaa with the Issuraw eovarap rM°
Apussorsam
plicant nsay.MCL ahaPter� i �2SCCn "N ither the cOMMenwasid'not any of do Pococuses for the performance of public work seeePtaDV°1^�a of compliance litical w oh t ie
enter mrtmenn this chapter boom p��to do cont<acdng authority-."
APPictuab CMPWehooddog the boxes that apply to your situsdas sad it
p o w a namoo(s compensation afildavit
es and yPhom n partnerships»>�i sir�s)of
odw than the
Y.supplyinsurance. LiontedLisibility (I I t�or Limited Liabilityinwraace if an LLC or LLP does have
mcnobers or PaUM6 Kee not mpoired to carry workm. c O°_ Department Of k&UUW
employees,a policy is tegirired as ur advised gs. �6e�to s>Q and date rttood0he a Ths ai»davi<should
Dqmtmcd
Of
hAccidents for confirmation a
el a return"to the c bwnf that insurance
for the permit Of license is being requested not the
a workee'
gbould you have any queatiast zEaer dint Les la if you mould companies should eater their
coulp no Aaudelic laao can the Deparo sent a the. number listed below. Sett
compesranc policy.P
self-insurance Iicesc��O°�O
City or Town OiSelaM The Department has provided a space at the botmes
Please be sure that the affidavit is complete and printed legibly. you regarding the applicant•
of the affidavit for you to full out in the event the Office of Investigations has r contact y n a g
Please tea sure to tin is the permttlhcense number which will be used as a reference number. In addition,sit applicant
applieationa in any given year,need only submit one affidavit indicating current
that must submit mull P under"�Sim Addme the applicant should write"all locations is__—(city
or
policy information( or marked by the city or town may be provided to the
town)."A copy of the affidavit that has bee officially stamped or licenses. A new afudrvit mast be filled cut each
applicantaa proof that a valid affidavit is on file for fbttaa Permit not related to any business Of commercial vanmw
year.Where a home owner or citizen is obtaining a Iieensa err Permit this affidavit
to burn leaves cu.)said person is NOT required to complete
(i.e. a dog license or permit -
and should you have any 4ueanonti
The Offis o f Investigations would like to thank You in advance for your cooperation
Please do not hesitate to give ua a call
and&z number.
e Depatoment's address,telePha°Q
Th The Commonwalth of Masachuseds
DquUned Of 1ntiOfW Accidents
Omer d v„adpdong
600 washingtOn Sftd
Bootees MA 02111
TeL M 617-727-4900 W 406 of 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-03 www.mus gov/ilia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 WMI-IING rON STREET 4 SALF-M, MASSACHIN:I I S 0197C
Tri,:978-745-9595 +FAX;978-740.9846
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 I I LS
Debris, and the provisions of MGL c 40, S 54;
Building Permit 9 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: pp
(name of hauler)
The debris will be disposed ofin
Ly
. .........
(name of facility)
U\
(address of facility)
-c of permit applicant
date
i A�dY I'S ede 1 1 ►�1<Q vY)\i N ��
0029 GARDNER STREET 806-07
GIS#: 6805 COMMONWEALTH OF MASSACHUSETTS
Map: 33
Block: - CITY OF SALEM
Lot. 0200
Category: REPARUREPLACE
Permit# 806 07 BUILDING PERMIT
Project# JS 2007 001237
Est.Cost: $1,500.00
Fee Charged: $25.00
Balance Due $.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License: Expires
Use Group: _ ANDREW BEDDEL CONSTRUCTIO SUPERVISOR-091369
Lot Size(sq. ft.): 5015
—Owner: BALETSA REALTY TRUST
Zoning: . ' R2
Units Gained`. Applicant: BALETSA REALTY TRUST
Units Lost: A T. 0029 GARDNER STREET
Dig Safe#:
ISSUED ON. 28-Mar-2007 AMENDED ON. EXPIRES ON. 28-Sep-2007
TO PERFORM THE FOLLOWING WORK.-
REPLACE DECKING,RAILING&POSTS T.J.S.
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Treasury:
Water: Alarm:
Sewer: Sprinklers:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2007-001516 28-Mar-07 CASH $25.00
GeoTMS®2007 Des Lauriers Municipal Solutions,Inc.