42-44 HARBOR - BUILDING INSPECTION What is the current use of tChe Buiiding7
cv ell I�
Material of Building? Lt ''��' If dwelling.taw many un'dsT
Asbestos?
Conform to Law?
Witt the Building � �
prchbds Name
Address and Phone
Mechanies Name
Address and Phone O l'��'� HIC Registration 0l«
Construction Supervisors license 11
Estimated Cost of Proied: NA� B Partnit FN Cakxilatlon
Estimated Cost X$71S1000 Residential
permit Fee i
Estimated Coat X s11ls1006 Commercfa�—.._
An Additional $5.00 is added as an
Administrable 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
sspecifications. Signed under penalty of periurY
Date i Zo
vl
0
� � a
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
::,.0 ur n LF.v I''rciicia i.
1.'oYtt 110 A'AMIN iONSCREET •SALFM. MASSAC!It.SI:rIS 0197C
TEL:978-74 9595 • Fvc: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 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:
's II�IMD�I � (GiVli ► �15�0��
— - (name of hauler)
I'lic debris will be disposed of in
(lame of facility)
(ad(lress of fucilav)
. ._Siraturac �icappucant
Zd q---
ia[C
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
anotttttt,r naocotL
MAYa
'M WA*ffCroerSMW a aK MAM1ACMWM0t970
7b-M74,&""a FAX 97L7e69ae6
Workers' Compensadou Insurance AHtdavit: BnlldoWContrae
Anudcant Informadom w.. PrintL
Address: Zl Q �
City/StatdZip: Phone t
An yam u ampisyer?Cheek the approprlaq bust
I.❑ I ate s employer with A ❑ I am a geaeal eomaeor and I T'Pe at 9`oIugs(regalre*
employees Ma and/or pnFtims).a have hired the wbeotmackea 6' ❑New cane uction
2.Eal am a sole psoptieoor or partner. listed on the attached shear,t 7. ❑Remodeling
ship and have no amptoijew Thee wb-oaauaceom have a. Demolition
working few ins is nay capacity. workers'
[No workers'comp,imam" s. ❑ We am a cerposaden end its 9• ❑Building addition
3. I equate&m a homeowner do' an work risk be"eaerdsed their 10.[]Electrical repaim a a��
mynah(No workers'camp.
iM Ott per MOL 11.❑Plumbing tepaim or additions
imuraeee regmred.]t comp o. 132.11(41 and on have no 12.0 Reef mpaim
�RL insu oc workn d 13.[3 Other
camp ioattaots required,)
'o r�e..ilde aWldwk•ya tin ae tw ned g wins G*ent 6=No dam•eemPremtaa Pdky kh meuea
tCanameaa det A"ddr bon mar mtaebr addt�de,dMj 6r��code ors am heat omtdt eaI a mom SAWA a now atlldwtt 6dkmbg emL rhm*11 tw mmm of din ro►eemeeme and orb wabma'eoq,Pray Maxwe�
Ian an rmpfoyn rest b prevfding works"'eosepantadom fnsupswe for fnjermado^ He/k w If the pefk7 smd fob dy
Insurance Company
Policy M or Self-ins.Lie.0..� I31/Un t)dt� L
26 D T
Job Site Addrep;�a Eapiratiw Date:
-tf� Nz�Yba� �. ciq/stuarLip: c a/v�Yr /f�{—Ay 97(J
Attack a copy of the workers'eompeand@M Polley dalereden page(showingthe
Failure to secure covers ar PG&Y number and espiratlon dap)6
W regecir9d under Section 23A of MGL a 132 can lead to the impoeidon of criminal
fine up tog 1,300.00 and/or one-year imprisonments,as wellas civil penelde in the form of a STOP WORK ORDER aomd of fins
of up to$230.00 a day against the viola mr. Be advised that a copy of this ststemeat may be forwarded to the Of}fee of
Investigations of the DIA for insuraoea wveraas veri}&uioo
Ida hereby cerdb mndor tke palm and perrefdaa ojpar/nry rear the fn
joraradon provfdil above b hms and correct
� o
71130ardof
use anf3t Ds nor wrf d In sib ores,to be cowpbred by city or tows ofjTe4d
Town: Permlt/Lleease tt
hority(cirrie one):
Health 2.BuUding Department 3.Clty/towa perk 0. Electrical Inspector !.Plumbing Inspector
son•
Phone*
F BOARD OF BUILDING REGULATIONS
{ t LicenseC�".�OO,N,. STRUCTION SUPERVISOR
NumbOS, .' pfit356
BrtdaQ3T1241flgtt
W Tr.no: We(5 3
O .
LARRY Y YOUNK', / q
li y 7 CEDAR BROOK
i 024
WELLESLEY, MA Commissioner
l EI'I'X-
PUBLIC PROPERTY
DEPART� vT
K INGWAL 1r D•ISC•L L
%94yoa
t 30 WA"Nanw ST &tom WNACH tTR 01970
111L M- 74&%"•FAX M740.914
APPLICATION FOR THE REPAIR RENOVATI N CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTIJIL OR BUIi DV(Q
1.0 SITE INFORMATION "
Location Name. Oulkfing: Mu I-H Cana i I CIF un
Property Address:- ` A- I�Aj golf 1S} .
Property Is located in 8:Conswva0on Area Y/N N _Historic Dhtrld YIN_lam
2.0 OWNERSHIP ii INFORMATION
2.1 Owner of Land
Name: P race
ss
Addre 13�i I (�i t i nuq S lna r� �r .
Qul� i OZl
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTV
Addition
Renovation ✓ Number 0f Stori �/
Change in Use 7�DemolitionL)Approximate year of Area per floor(s /
construction or renovation �Q p \/I,S ��U
of existing building ( New
grief Description of Proposed Work:
��� ��Y�— �f e o r� �'��ac.2 lG�-E-r.�U-• Ga,>4 w�,,�}S . t,PNi;t�4-Z �
( q A-ev&tt
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Mail Permit to: - -