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84-86 HATHORNE ST - BUILDING INSPECTION
fL What is the current use of the Building? units? VN;E Material of'8uilclft4 s If dwelling,how many Asbestos? WW the Building Conform to Law? Architects Name ( 1 Address and Photo Mechanic's Name —' Address and Phone /S Der/�'to'7 HIC Registration fi Construction guPervrsors nss ------ Uce Estimated Cost of Project PermM Fee Cakwiatlon Permit Fee i �� Estimated Cost X$71S1000 Residential EMM ated Cost X S11/51000 Comme►eia---- — An Additional$5.00 is added as an Administrative Make sure that an fields are property and legibly written to avoid delays in processing. The undersigned does hereby apply far a Building Permit to b to e spech,catl�• Signed under penalty of Perjury e S O-7 r a a _ 'BOARD OF BUILDING REGULATIONS �{I , Uogttge. CONSTRUCTION SUFERIIISOR z 33 Nutobae CS ..,: 081867 c - Birth 05WI976,' ;Expires 05126(2008', - Tr.no: 26813 ns- { HILARIOM CUNFI',, 0E- J` { 1 PURCHASE SALEM, MA 01 Commisalonar 17 Board ofB B Raiidiu 'teo�l/;of"✓�.¢atar�v�ll.�` k - ; aBolatlona aqd St"clards „ HOME IMRROVEMENTCONTRACTOR mot, Regiatr46n: 1;I6261 a n 1;_xPlretl3713t2067* v :. 1 _ T _m�dmduai,. ;}t HILgRIO HILP,RIO CUNyA r 165 FEDERAL STREET ,p ' SALE 01970 �L"'—•�` ✓ 'ddminlatrator � fy °.� CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT \t% ol; 120W.N.9[ING7QNSMET •SALFM. MAS.N'.%C%U iLI-ISOi)1Z Tn:978-745-)595 #F.kx:978-7+0-9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code,`7S0 CNIR 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: i � r G (name ofhauler) The debris will be disposed of in (name of facility) I:1lIl:rCll UI fal oily) i ratwc of o'ni'a avl)"cant---- _ 6 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT tcasasust traaooti ,dw uo wn:tmet:ra SUW a setae,MANAC etWM GIWC ML WW454M 9 FArc 9W4*."ft Weritarae Compeandes Inswaam A!lsdav(C Banda l/ca AnnUcent Infermatba Hem wt..e Lam Name Addtts /o Diirc��-c city# PMW P Ate you an ampisyW Cleo!the sppanpdaft Was 1.13 I m s employer with 4. p I am a poard carameaor and I d. of Project Mil and/or paeadme}• have hired the ❑Now eaoruoeBae 2. am s solo psopeletar or partaao- Hood as tha anachad ebnt.t 7. p 8amodsliog ship and have an amployeat Then wb•ooetragom haw L p DamgM= working Aar met In any capacity. workins$snap,inomama. (No workers$comp.ms uaaa S. p we Ana corporation and is 9. p Builft addition 3.❑ l hat aowaer oafaes bow mroreised dmdr la•p Macaw mew or additlma Going all wait tight of mtmapdm par MOL 11.13 plumbing rape m or addidom myseit(No workers,comp a 132,41(41 and see have no 12.[3 Roof regain 10e"s� )t employees,Din workero• 13.p Otiter Camp6 mmraoa mgaiteLl ;ti9 Wfto ft dada twoet man alsof01onda section bdmrsteelyaskvalor' ttmre....Who.nYaiemerEdaermdas�s+ryaaadyd.mr.ta.uaameYeam no sumo it now Ifildwir bmeaft tco.a.as.due cbA e s ban norr timed r.dewa.r dhow as.lye...e arar a►ea.r.aoa.rl awk aabaa•des+ foiamatla� Gs/orwad rAd LProvfdmr worRas'eewPrmredoe GunnwceJor ary rssP/oyrµ Brber 8 tAePOMW Nam rAtr Insurance Company Name: Policy M or Self-ins.Lie.M Expiration Job Site Adidress City/ShtalZip Attach a copy of the workara'eompaasadom popsy declaration pap(showing the policy number and a:pka&a"")6 Failura to SUM Coverage ar rapdred Under Section 25A of MOL e. 152 can lead*the imposition of eriminal Panama of a fine up tog 1.500.00 and/or aowyear WW sonmem,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to 5150.00 a day aping the violator. Be advised that a copy of thin statement may ba forwarded to the 0t7tee of investigations of the DIA for insuraoea coverage verification. /de hereby ardJj tAoe PrevAdisf L MW correct PhoneM O,QTefd rase 04 Do mot write In rA&rrre,to be coaO/rted by eby or lown of jlcle( City or Town: PermltJLkenet M Issuing Authority(Circle one): 1. Board of Haith 2.Building Department 1.Cit UL Other yfrown Clerk 4. Electrical Inspector S.Plumbing Inspector Contact Person: Phone N:_ � E ©Fg -- PUBLIC PROPERTY DEPART&IF.1VT iawE1Lfir0uscuu Nwvat 131 Wtivurw►tw SntFgK seas Ot970 nL.m745.9S"•FAX:97L7d0.9SK APPLICATION FOR THE REPAIR. RENOVATr N CONc'rRUCTION DEMOLITION. OR CAANGE OF USE OR OCC M&t►rry FOR ANY EXISTING STRUCTC�p OR BUILDtllyr 1.0 SITE INFORMATION Location Name Tfq-86 4 rjv. -r—Property Address:---- Building: - ---- -- P vm tY Is located in a;Conservation Area YM Historic District YM 4.0 OWNERSHIP INFORMATION 2.1 Owner W Land Name: ��c JRc eSo�✓ Address Telephone' `978 - Sb9 -/S76 3.0 COMPLETE THI8 SECTION FOR WORK IN EXIATINp BUILDINGS ONLY Addition Existing Z Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor(sf) Renovated construction or renovation Of existing building New &let Description of Proposed Work; Mail Permit to: ZFy -