59-61 HATHORNE ST - BUILDING INSPECTION (2) CITY OF SALEM
_ PUBLIC PROPRERTY
DEPARTMENT
M.Nyox LQ WASI It%*CiON S:REET •SAL LAI. %I[MiAC IL*CIS 0191C
Tn:978-745-9595 * F.,-X:978.740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
I In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
!I Debris, and the provisions of MGL c 40, S 54;
I 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:
I
iname of hauler)
I'lic debris will be disposed of in
/V 6-1 (1 s l
sp �
(name of facility)
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CITY OF SALEM
PUBLIC
PROPRERTY
DEPARTMENT
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Areseb a copy of tY werkan
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faihott to swum coven a. p.araeWa policydeelaratl a page(shawbg tY teb
"liky aaer a"upkaden date}
ga required under 3ecdoe 23A o(MM a 132 an toad to td imposition oraimind pttaido ora
Ana"p to gt,soo.00 and/or om•yerr imprisonment >.wan u civil peaakiae is dr form ora STOP wOR><.ORDER and.Ant
or up to$230.00 a day aping tY violator. 3t advised that,a or
Investigations oath.D1A tar .........���vaiAeatioa °cy �fd0�may be forwarded to the Otlioo of
f do Messy COMP under
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City or Town:
Permit/t.keatt•
Issuing Authority(circle oae)t
1. Board of Heeltb 2.Building Department 3. Cttylfown Clerk 4. Electrical inspector S. Plumbing Inspector6. Other
Contact Perrot•
PUBLIC PROPERTY Uy��
DEPARTINIFNT
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APPLICATION FOR TSZ REPAIR RZNOVATION CONS ICTIO_N .
DEMOLITION. OR QMSZ OF USZ OR Efi FOR ANY EXISTIIV[�
STRUCTURZ OR B m.ntlnr� --•-�:_
1.8 SITIE INFORMATION "
Location Namee g ,s:
Properly Is located inn:Conervidon Ares Y Htelorlo Dlitrlot Y
S.6 OWNERSHIP INFORMATION
2.1 Owner of Ls"
Nine'
Address:
TMepho w. -! k—
3.000MPLETE THIS SECTION FOR WORK IN EYIIIIING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
A oxim
PPr ate year of Area flo per
construction or renovation P or(sf) Renovated
of existing building New
add Description of Proposed Work:
Mail Permit-to.•
What is tM cturent use of the Building? XL s 1t0e1 2"4
v sa .D If dwsding.how man!►units?_ 2
metarid of BUROV? Asbestos?
Wits to&Mdk-4 Confer to law? TES -
AWJ"ds Name t
Address and Phom
Maehanies Nante
Addreell
J -3
Cons Supervisors t.icatse is a is HIC Reghsatbn aY
Esth+afed Cod of Project$ V � Permit Fes Calaulatlon
Permit Fee S EsWnded Cod X=7/:1000 ftesWertial
ar
EstYndsd Cod X=11I=100o ComrnMcia�- -
- An Addbnd$5-00 Is added as an
Adr wddraWa c w9dL
Make sure that all fields are properly and log"written to avoid deli"In Proeesdn0O
The undersigned does spy apply for a Building Permit to built to the above Stated
sue, Slgned under penalty of Perjury
Date
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