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26 IRVING - BUILDING INSPECTION What is the current use of the Building? It dwelling.how many units?---- — Material of Building? Asbestos? "I the Building Conform to Law? Architeds Name Address and Photo 1 — Mechank's Name 'i L Address and Phone / 7 '7� Constnx tior►Supervisors Ucense ar�—HIC Registration A �y----- ; � ©O D Permit FM Calst X S n Estimated Cost Estimated Cost X s71S1000 Residential Peooit Fee= _ Esdr ated Cost 11111MOO CommwcW--- An Additional$6.00 is added as an Administrative charge. Meta sure that all fields are properly and legibly written to avoid delays in Processing. The undersigned done hereby apply for a Building;Ormit lbove stated S ned under penally of Penury „ �lspocillcatbne. ig Date0 7 I N O � Oy d� 0 �t a ; 3 4 _ i w CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ,.Ati;rh IET!�RISCOI1. \U YoIt 120 WASI UNG ON STREET 1 SALFM.MASSACHI.SL 1-IS 01970 -rPi:978-74 9595 •Fax:978-74G9846 Construction Debris Disposal Affidavit (required fur 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 16 c 111, S 150A. The debris will be transported by: (name of hauler) fhe debris will b/e- disposed of in (name of facility) I❑ddre55 of facility) si_uature of permit a41)1111 date CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT cn.attarnr n.acotr. a4tina t20 WAgmwToarSSear o LUM mTTs01970 TM!71.74"W a FAX 9'ri,7l*%% Worker* Compensadon Imur nee Affidavit Builder/Con Anofieaat Itah madoa , \\ Run t#.4,.►r.edl.sa xatate 1 �tJ t,ti9., n 4 v� e�✓`� -4A I Address: `� t S � ,�.r o rt� 5•j— _, Cityistata/Ztp ��a n v� �M A Phone)I S 9 1 I Z 1 1 AM you u ampMyerT CLek tie appropriate kw 1 I as a empbyer with 4 D I as a good contractor and I �� =Playa"(iirR Bailor paet-dm4o haw hired the 6. D New construction 2.01 am a sole proprietor or Pmmeo- hated an tee attached shoat,t 1. D Remodeling Ship and hew no employe" These ab.000tract m have L D Damoudm working bar me be any capacity, workew camp,imausmL (No workers'Camp imanana J. D We ss a corporation and its 9. 138mildina addition 3.[31 am a homeowner nVaked Odkma haw exercised their 10•D Electrical repairs es additions doing an work riser otermtprys Pm MOL 11. FhrmbLtg repairs es addidow royal[(IVo workers,comp a 112.41(4�and gars have no 1 inaur+oa tom)• employeaa(Ne wakes'can 13. otter ;Any AsP�•srdwb tm r W!MEN Was m am dissection hegr tloe6��q p—qL Waterloo ' HeelpesatlaaasYaYambaamdlaHgdWMdoingrredadrMwaanWovWwra11 p70M alaalrY aAlirltiaiaartaar0i tcamorawa to Shalt era tar am snub"a oddWanY Shaw&SW*err sae af6a aoMeaeeepew at ever awtwo'aq Per Iaarotlae. laeao eiaf!t prov!!leg worArrs'rove • podb an/ stets J Awaroseefae my rmpfoypa BaAnr 6 tAe Insurance Company Name: qV/�i 1 N� �/1 v TV I C,Policy e es Self-im.Lie.N:_ t WC 7 l�I . /7��-3 (7�— Expiration Darr. 5 I - 0 d Job Site Address I Zl 1�V] a ,1 1 ")A c-G Ciry/Shts/Ltp Attach a copy of the worker'eompaoesdon policy declaration pap(showing the pagey aambar end axperadon date} Failure to secure coverage as 09 and under Section 25A of MOL a 152 can lead a the impoaidon of eriminel pemalti"of a first up to f 1,500.00 and/or ors-Yeti imprisonme�as well as civil penalties in the form of a STOP WORK ORDER and a Rao of up to 32S0.00 a day apiau the violates. Bt advised that a copy of this sratememt meY be forwarded to the Oulu of lavestigations of the DIA for insurance coverage vcrilicadon. /do hereby ce an?p do an/ n o per/v7 rAw A*Inlormodoa provided above L mw a"emp ea phJ�Iw-- Phone M: q 9 — 1'L 11 OfJfehd ore oah)t Do not wrim!a IA&areal to be complrud Ay dip or Wwn opc&i City or Town: PermltILIeeme ti Issuing Authority(circle age): I. Board of Heslte 2.Building Department I CltYfTowe Clerk 4. Electrical Imptdor S.Plumbing Iaspeetor 6.Other Contact Peron: Phone M:__ EITY OP'�ALE� PUBLIC PROPERTY DEPAR'i'1VIF.�JT W.%AUX NORMCU t 130 wAswNcrcw�17f=9 SM"4,,MASAC HLstirs 01970 TEL M- ?4SAS9S 9 FAX-97e.7J0-"46 APPLICATION FOR in REPAIR, RENOVATION CONSTRUCTION DEMOLITION, c t1Arr O OR FOR ANY EXI TIN STRUCTC�� OR BUILDnvr 1.0 SITE INFORMATION Location Names Building. -- Propeny Addrosev--- f=ervation Property is located in a; Ares Y/N Historic Dlsbid Y/N 3.0 OWNERSHIP INFORMATION 3.1 Owner of Land Name: i >�� Address: W Telephone. - �O — 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTM BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor NO Renovated construction or renovation I of existing building New Sdef Description of Proposed Work: Mail Permit to: / l° 60-o n c S J— V .