42 HATHORNE ST - BUILDING INSPECTION r a
What is the curent use of the Building? If dwelling.Material of guildingT �¢oc� �how many un
W it the Budding Conform W Law? asbestos?
Archited's Name ( )
Address and Phone `
Madtanic's NarM
Address and Phone G < HIC Registradw 0
Construction►Supervisors License is ?
pLmd Fee Calwlaf w
Estimated Cod of s— `
Estimated Cost X i7/ti1000 Residential
permit Fee i
- EstYnated Coat X$11/$1000 CommwciaW-- -
- An Additional$5.00 is added as an
Administrative charge.
Make ure that all fields are properly and legibly written to avoid delays In Proeessing.
The undersigned does hereby apply fo►a Building permit to build to the above stated
specftatkms. Signed under penalty of perjury
Date
� 1
6.
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EITY-01 guml
PUBLIC PROPERTY
DEPAR'I'11dE,�1T
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uwraa 130 WAaunGcw S'MM•
•„" NAssAanscIn01970
TM MUMS"•F,Z M740.9W
APPLICATION FOR TSE REPAIR. RENOVATION CONSTRUCTION,.
C
DErtOLITION, OR CHANGE OF USE OR O mANCy FOR ANY FM
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name ,Z lard Build(ng
_._ ..
Address:-
Property is bcaw Ina:Consarvadon Area YIN Historic Dktrlot YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: GG// L 1y/Je
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(s0 Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
— — Mail Permit to:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ldttaron, uo.en,eewsa,staQr.sau>w wnetac,�rtseisro
Tfta svW4$."n o PAtk e7L710%%
Wtttit W Compundes Iunraaee AtNeft BllltdenlCo
Nance r f1 ee , yam .
Adafmw 32f 1,,Ae -3,- ,-Z
cityl 9 ram.* _.
An ye}u Mpta>.r!C1Kk yes approprialf ran Type orpred ' e
1. I as a smplsyer wbr /, 4 Q 1=a vend coos"and I
(!b8 soNer pere•t m4* haw hied the d Q "r amrrttedon,
2.0 1 an a Who pseptiaeer or portam listed as the an,aohd+heat t 7. Q R.moddieg
ship and have se employs These have p Damoiir
Washing for me be my sty waskew comp Wanesoe.
(xn wartms'comp.assurance 3. p wean a corporation,and•ore 9' p anift addidos
3.❑ I hammwnnrj oflleas haw Wen dad their lo-p married tapsin a additions
dabg ad war right of aampim per UM ".1nPhaniftmWaoreddhicass
myrrh(Ne warren'C=06 a 15%f 1(41 and we have m t2
insumet )t employees.DID wsrkes 13.Q Othnr
lima immmo.
►�sevr•+sretrrbha n saM rdee®ar usswaakde.rkswla-dniwakas'
tta.so.rswke rriaa am amrvk idlerty br..w.f.f..r.f r r.aver a.. 1ret oM.w�tl°`.....elrr 2Co.r.arw*Nru1kd1btanashi obseaaddd"shmembli hadd*ranee•COW venterida.:Ws.
Ulmrhar 6 perry�werRors'eow`p/wade.lauMuraJbr q eayfryesy sibrr 6 the po ft and job rich
Insurat"Company Nam. i /i[ 9/0--
Policy N Of Se P=Lin.ti Exptrstioa Dun
lob Site Address ph/3hh/Ltp
Attach a espy of the worksre'eoorpewtion,polky doderstkn Pap(showing the Poday amber said exptratlw daft)6
Failure to seeun coverage to required under Seetion 23A of MGL a. 132 can lad to the imp ""of criminal pWW"of a f m UP to f 1.300.00 and/or one-year imprisonment,as wall AS Civil penalties is the form of a STOP WORK ORDER and a Ace of up to$230.00 a day against the violator. Be advised that a copy of this ststemant may be forwarded to the Otliu of
Investigations of the DU for ineura m coverage variAeatiaa
/Jo lbnlp arN/jr mold"
oJpr/rry rim rAo/a/ornr sOrorl/e!chow/s 4 st Na eomret
ofJleld au ofith Do as write Le Ab arfd&to bo eesrp/eu/byClip or AMA 04*14
City or Town: PermlNLleeaes
issuing Authority(circle one):
1. Board of Hedtk I.Building Department 3.CitylTows perk 4. Flecirieal lospeetar 3 Plumbing Inspector
L Other
Contact Person s►.__W
w°.� CITY OF SALEM
PUBLIC PROPRERTY
�'�" DEPARTMENT
\t.lrrv` im Vt/.\SI IIXt�[UN SrREET •SALt.t,StASSACHt sL rrS 0197C
Tri:978-745-9595 •F.+x:978-74t}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 ofMGL 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 1.50A.
The debris will be transported/by:
_ cl r _�
(name of haulzr)
1'hc debris will be disposed of in
(name of facility)
.. .._.__.._ (address of facility) .
Si_ratu,e of p kit appacaat
,iatn