15-17 HARBOR ST - BUILDING INSPECTION o
PUBLIC PROPERTY
✓��O _ o� DEPARTMENT
Kisas EY OwCOLL
MAYOR 120 WAWINGTON S7REEr•SALEK MA\\4AcHM-175 01970
Trz 978.74S-959S*FAX 978-740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
property is located in a;Conservation Area Y/N Al Historic District Y/N AL _
2.0 OWNERSHIP INFORMATION �/y,��ja� �L LLC ,
2.1 Owner of Land 1,c l
Name: filq A/' YI
Address: r sue'
Sri/e r✓I �� ,
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use .3 New
Demolition Existing
Approximate year of }_ Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
l� eo'( & UlaitS Pam w0t-s neu�ols� �ebris 1 ��se I
3� ,nGplaCe go1.v1? e-J, 9- II& 1 v.+er-1or c�ovrs, .replace
eP.�s1 ivy a�o i�it�ces
3) build im�er'%or r&rz'1+� ILs for cloSEts •
-1) (X" poleu'F�a1 K�icf�s o� DkgkS W'r�•l, vtii+s
Pori►Ie
----Mail Permit to: % /��o�tdw��l C.��e�i YY14• d2/�/`% ---
What is the current use of the Building?
Material of Building? W O" -F rA w p- if dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone )
Mechanic's Name yet) b-e r-t- k l e l—
Address and Phone 231 Al 6 2 TO tU
Construction Supervisors License# 0 4 3 It$ S HIC Registration# 15 j 6 `7
Estimated Cost of Project$ Do0 Permit Fee Cal Mallon
Permit Fee$ yyS' Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additions! $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the abov tatqd
specifications. Signed under penalty of perjury
Date
lid N
w
3
CITY OF SALE►m
PUBLIC PROPERTY
` DEPARTMENT
w�uaroara�a
MOM 1'J�I llftR.s.�wxa.aca�s01f7e
Ilk 97&7464M 0 PAZ s USAW
Coiistrai<edos D*bris Dbpossl rlMftvit
(segairad Air stt da omft and mava"wadi)
Ie sooasdaoa wWt ebs a a( 9 Hai CWk 790 C!�secdom 1113
Dediti ad
eUMOS irerndt d is bond v ttt dw 000d< m dke dw debate res Abs[foal
dds wwk"be disposed o([s a P0b named waste dispad bd ttlt as defined by UM e
1u.s1lM.
The debris win be Usisposted by:
r �1�►e o.V4 51) s
(a.me s[braisrl
The&bds win be disposed o[to: q
wmj
(same o(fxiliM .
rL�daaa ar
u,wa4m at sit�pOtiaue
da.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
rnraouatt tancou.
�IArca t20 VAstmeGrots STRUT a SAI M MAsLU3RjWM 019M
TIL 9W45-9M a FAX 97..74MM
Workan' Compen.attom I=11raaee AfRdaft BWdaWContraat0nM
AnoB¢ant Intormadom Pfe o Print r.aeon~
Name t y fQb b e rt ko k l-e r-
Adds.: 55 MQ 2-rD k) A•U eUu E
e[ty/st:ceiz(p: 1M E b F-01ZQ ,_ Phone* �� [ ? - S I o - 3 7 8
Are yen as employer?Cheek the appropriate Don
LP I sm a employer with O"ke 4. 0 I am a annual contractor Rod I T�P@ djest(requlreo:
employees(tan anNq have hired the sub4on&wmes & ❑New eaRehnetion
2.[31 am a sole proprietor or Power. listed on the anaehed chest t 7. aRemodenng
ship and have no employees That sub-000etaemeo have S. ❑Demontfaa
working for me is any a 9. Building capacity. worltera'�.iogtranp•
[No workers'Comp.ioattranq S. ❑ We am a eerpoestion and id
regrurad.] otBeem have eaetaind tGde 10.®,E10etrical repairs or additions
3.❑ I so a homeowner doing an work right of exemption per MGL 1 l.61Phrmbing repairs or addition.
myself.[No workers'comp. a 152.41(4).and rya have no
imuranee requited.]t employee (No workers' 12.Q Roof repairs
camp.insistence required] 13.0 Other
r�wM�Nor aaatb tea st not AW a.as tea ratttaa brlow tee cry ere wvama
ItanrowaswaitsntbuMthltaahYait6ttlntlagCryamdone=dwedtudnotheaottdtao �rAb"iggspaffidwy tCoetraeais tart chaste this ban mot son"as addWaad Ayr 'tri td area der rab.Coaasarw am owle workers'Coup,Poft inibnooks. .
tiler bt prov/dGj worAaal'eowpewaoaf�ow
WIMMIMdom
lmsrraweija air earp/oyep Eefmr b aha pa!!er amdJori sb7r
Insurance Company Name: Tr-olv�`'e 1- 1 V 1 e 1M Yl i CIO U.4- OL
Policy N at Saltine.Lie. _ C Expiration Date:_ 5 ZO � o r]
Job site Adaresa 1 s-12 Harbor S tr e e f City1Statol2: . `Ja le w,, W et ss,
Attach a copy d tDi workers'compensationpolicy declaration pap(showing the policy number and oxpiradoa dab).
Zdur s 0 am=coverap so rcyuhed under Seedon 23A of MGL a 152 can lead to the imposition of criminal fine up to$1,500.00 and/or one-year imprisonme�as well as civil lsenalt a oh
of up to 3250.00 a day against the violator: Be advised that a copy of thisf salt may
oe l STOP WORK ORDER and a Rue
of
Investigations of the DIA for insurance coversp verification, maybe forwarded to the Office
/do hanky card
&ender do palms and penaWn o/oed my that rite br/ora"d0x
+'�
��, o n x� � Prod above L bon and conrct
Signature `� \ /l� Date 1 A l (0 `
Phone Ar (o ► �) - 5 I p�_ °l 3`l S _
oJJlcwass 004% Do am wrfie in rhL Men,to be coatp/ W airC4 or draw o,Q7ela(
City or Town: Permluticeme p
Issuing Authority(eireie one):
1. Board of Health 2.Building Department 3.City(rowa Clark 4. Electrical Inspector 9.Plumbing Inspector
6.Other
Contact Person Phone M
Information and 1ns�ruCEIOM
ylayysCbusetts Geneal Laws chapter 1 S2 cerpim A employees to provids wwkeW co'n"ntston fa'heir emploi*Me'L ..
punt to this snn'm.an e�is defined as""XVM pawn in the service of tutother under any conuut
express or imp"oal or wsnem."
atsoeiatinn.eorPacauon or other legal mtey,or any ewo'ar more
An estPI�a defined di"tm individual.w%and i P the legal,represeoteaves of a deee plo ems�•am the
of the foceiO1°f��1°� h esaocetiom air other Inn entity.®ptwji's emPloYar
receiver or trustee of so indwWual.partnashtP• ad who resides tbacin•or tho oixuQaat of the
owlet of a dwefiing house bavisg not nine three apattaaents do maintensock eooatntctins oc 1eWr watt as such daeltbg house
at on the grain of amthar who empbya Paso"msholll such employment be domed to be an etaPW)W
at on the grounds at building appurtenant �
Meg.Chester 152.12SC(6)also"Mtbar"every state or local tica�W awl•W Leo�ter a W
renewal at a Skew of Permit to�a a bmintis er to a endr d balldlaV coverage requireV
spoksmt caw teen net predae�a PCOOM eawmmwit nor any tb politicalions sball
Additiaosuy,MciL chapter 132.125C(71 le evidence of comptiaoee with the ittaurasce
tab
eater into any iwnerace far the performance e[P .
requirements of die cb Asa bsv�bees presented
to the contracting au*Oft-!
APPAC"ta chocking the boxes that apply to yore sitaadcs end,tt
plCess fill au the wodma'compensation affidakovjt 'hY oKes)and phone numbe (s)along with their cartiIIe+mU)of
necaosery,t united L'COO ' name(s),ad ar Limited Liability Parmesships R'��no°mp101`ar°��the
If an LLC at LLp does have
ma�patmea,ace not required to carry wodcers °Oinsurs of Industrial
� 6 a Polley
a r� go advised that this affidavit may be submitted m the Department
Accidents far confirmation of insurance C°Veage' Abe be sate to dp aid date the MINAViL The affidavit sh not the Dapmuu*d y
be returned to the city air town that the application far the permit of law Or ifyUna is b0otr are tO4�0dmPeAtOd to°�°s wO '�
S wild you have arty que tlonrxUmd�
Industrial Accidst[W compostoadoet Alley,please Call thM Daparemant Can below. Salfioaured companies sh°u1d aamr their
sel(-htmttaom—Incense mwber on the
Clq or Two Offidsh
��� the Department has provided a space at the bottom
please be me that the affidavit is complete and printed nos has to contact you regarding the appHcant
of the affidavit o you m till our in the event �� used as a rtfa�gybes. In ad&dM an applicant
please be sue m fill is the pemitrlieease lirntims in my given year,need only submit one affidavit indicating Current
that° subunit ided
�e �"Job Sim Address"thn applicant should writs'all loudona is mv or
poles t"A copy of( thet has been officially stamped or mucked by the city or town tray be p
to the
town). A CePY of the affidavit a on fib far Aurae permits or lieetses. A new af..di vir most be tilled oat N&
applicant as proof dial a valid atYfdsvit not related to any buainw ar commercial venture
yew.wheaa a hams owner ar citizen is obuioing•license ar permit
Y or to burn leaves etc)said Penn is NOT required m complete the affidavit.
(i.a a dog license Pau and should You have any T"dOo%
The Office of invaaitpraons would like to thank You in advance for your coopeatien
please do not hesitate to files us s ca1L
The Depacenast's address.telephone and fax number.
The Conunwwe"Of Massa bUd1s
Deputllmt of b sviv Aeeidata
Otbe d lsvtisdpllosg
600 a/a hM9M Sftd
Bodo%MA02111
TeL 0 617-727-4900 act 406 of 1-877-MASSAFE
Fax N 617-727-7749
Revised 3-26-05 wwwmaagovidle
:- - BOARD:OF BUILDING REGULATIONS"
License: CONSTRUCTION SUPERVISOR,
,>
Numbe,4 043185BI
E7 —6 1 007 Tr no: y10010
Ia _ ROBERT J KVE A
59 MORTON AVE
MEDFORD, MA 021
,k Commissioner ,
I,
I
II EI`I'Y-OF�XLEb
PUBLIC PROPERTY
DEPARTMENT
Ki.%QIFALEY DW5c:t1LL
MAYo� phi 120 WwuNG"SMEEr•&U.LK MASSACHLSLI-M 01970
TE L 978-745-9595*FAx 976-740.9346
APPLICATION FOR FPAM RENOVATION. CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISnNG
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name:/ -/-7 4/ o Sf • Building:
Property Address: 14urh o l 5mf'
Syl(fm Mcf - v /9�o
property is located in a; Conservation Area n/a Historic District Y A�)D
2.0 OWNERSHIP INFORMATION/LJq ek)-bi✓l NG IL L-Z-
2.1 Owner of Land -pWA k UJ
Name: �AtI heLv h 1 b r1
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYICTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use N//� New
Demolition Existing
Approximate year of /�1/f� Area per floor (sn Renovated
construction or renovation ;7 New
of existing building
Brief Description of Proposed Work:
?a L 12 6;q�l�co o s I z Y-3 rG tee' S
Mail Permit to:
What is the current use of the Building?, V Nv S 4
Material of Building? WOE'S lic fAf'fSr If dwelling, how many units?
Will the Building Conform to Law? X Asbestos? /At
Architect's Name
Address and Phone GZ o `M ( ) !oi 92�i-99
Mechanic's Name u la c y„ go
Address and Phone l
� ! r
Construction Supervisors License# HIC Registration# "
Estimated Cost of Project$ moo Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 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 a "es ted
specifications. Signed under penalty of perjury X �l We
Date
of
N
0
4,1
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a
gF d C� > °
a u a a
.a - — --- ------ - - --- - ---- - - --- . -
i
CITY OF SALEM
PUBLIC PROPRERTY
- .
h :
DEPARTMENT
tnaastsYcsaooat. ,
MAYM _ 120.�w4QJGTOIVSI'ft3[�SAttM.IIA AQR7f!'rtSC1970
Tres 9W45ftIs a Pus 9M4o ft*
Workers' Compeandoa Imursaee AtBdaft BaUdaWCon
Aani nag Iabrmatilol ' . PIUMPrIBILAdh
Name i-
Addca.e A Sg �'1'10 2T� rL1'U E�U.G
Ciryisb,,;zp: - 9 37 B
An yes as onplayee?Cheat the aypropehq bed
1.P I eras a employer With O Ke 4. J I am a pmral emmaraor and I L New eaenus tree
employees(nd sndl� have hived the subcotmacems
2.0 I am a mole proprietor or pstmam Head on the asecbod abeoL t y ®Rmnadofi
chip and haw as employeat Them aboommcome have L 0 DpmoBdaa.
bt me h my eapadry. Wakem'coo*hNUMMOV.1 9. 0 Building eddMm
(No walkers'camp huninu p 3• ❑ We aMM a amputation and its
requ.��,y,7...�� - , "' - officers bow atembsd their. 10.®,Eleetdesl+op"or addidons
wr) • y.�
3.0 I am a bomeowiser doing aB arork right of mamptio s per MOL 11.GYP�g repairs or so"
toys.([Dill Warners'camp, s.,132,11(4)6'and we havwm 12 0 Rooftepaire- .,
insurance rogatited]t employees.(No Workers' 13.0 Other
•Aver ayploa pn chefs oas tl mf dr M m u..ala.ato.atioerfy elak.adad-e..p.wla.
Here Uftm*sYAlre MR,
arYiedMerlyQag ewdriydwak iraisasWreeraalsasrrimsrfawelBOrrtiireali�aee<_
Accom esmdoch"Abbmvoltrschdied"M01AMchawfea6re�eofiYeaieaesaassdmakwade'oes� posyt> lea
on aw atybp►tit b weeken'eear0ewsdow lwaswwetfsr wry employees Behr b ahtPAflgr awd/at;tdM
Insurance company xww 'FraV�e d• rT' J.y) Ol e w yt i f 1 l.O k" p&t k j
Policy 4 at scif:ins Lis:N_ S OC1 $ G 0 (p o NO EVitationDaW. 5101 0 7
Job Site Aadrea I s-�� Harbor . street Ci1y Sa le"vu W 4s-e,
Attach a Cops'of the worker'eoospeesadom polity declandee Pep(showing the Pitt aiudW sad npiratloi daft)
Falb"to Soww coverage as requited under Seedos 2SA ofMOL'e. 132 each lead to the impod&6 of a hWnW pt ashim of•
Ron uP m i1.300.00 aod/er one-year imps ss well a civil penalties in the form of a STOP WORK ORDER and a fbw
of up to$230.00 a day against the violator. Be advised that a copy of this smtameot may be forwarded to the Ofllcs of
lavestigadom of the DIA for insurance eovemp vetidemin ,
lore kdrey Caster awder&*PALM ewd 000107 40 As Lformedlow pwiddd above Is arc OW Comes
Sinaturm &:Lj— a � K" . Dam:
Phone fl: to l q — 516
Of e'd We owi)t eve AN W&L ekb ono,ro be CoMBl y CAP or tow ofjfeld
City or Town: Parmitaken"d
Issuing Authority(circle one):
1.Board of Health L Building Department 3.Cleyfrows Clerk 4.Electrical Inspector L Plumbing Inspector
L Other
Contact Penes: Phone N:
CTTY OF &uEm
PUBLIC PROPERTY
DEPARTMNT
��
coasbiKdo. Debrb Dbpo d AMdsvu
on"" 0 Ida.■mq
Ts som ams wigs the dz&: s��°[s�70 C.!► I SOWM It t.S i,buds dw emm"drat d dabsts s!toot
wall dWl Otis s yto�b bawd VIM di pnd MOW a 4WbW by MM s
Th@ddxW win b6 ft=q osad bF
0, SO s
Ths dads wilt be dispaud of is:
605+0-1,
(um.a<AailiM .
due