21 JAPONICA ST - BUILDING INSPECTION What is the current use of the Building?
Material of Building?
if how many units?_ ----
�,��
Ma tt+e Buildingrm
Confo to law? Asbestos?
Arahited's Name 1
Address and Phone
Mechanic's Name can
02/ i Uc�rf.a�+� % ��-,r-t . c�..9 7a
Address and Phone
Construetion Supervisors license N f' 4 C> HIC Registration 0
Estimated of Proled i D '- >`> Perron Fee CaleuMtfon
Permit,Fee —d Estimated Cot X$7/51000 Residential
Es*nated Cost X S11/i1000 Commsrc4'L---
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are Properly and legibly written to avoid delays In Processing.
The undersigned does hereby apply for a Building permit to build to the above stated
specificatlone. Signed under penalty of Perlury X
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\til c'1: 110 WASHNCiONS17BEET 1 SALP.ML MASS\CiUSLl-IS'7i97:
TEL:978-745-9595 1 FAx:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit # _. -- — is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
------A_ �S
(name of hauler)
The debris will be disposed of in
(name of facility)
addmi5 of fucililV)
� 5q �
� �� � Q �� �- si .oturc of pcnnit applicant
uaLe
n W
W
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xn..nnnt aamoord.
ut►9om 14.A*IM-M ft=T*SAL114 MAXACUITIS0t970
Tet:97W*ft*a FAX 97W40,9W
Worlms' Carmen mdn's I=urn"AM& tE BWMW$lCo
AnnNeant Iuh Aides
l>h r 1A4we t..tsu.
City/ststdZIa_
Ap you am ompllsyar!Check the appropriate km Typs t.� 1 as a employar with 4. 13111111 s Smug contractor and I � �
employoa(Aril Anwar part-dm4o have hired the 0' Q New eoostr acdcas
2.01 tm a sob proprietor or parose. listed as the attached aheet t 7. ❑is®odeliop
ship sad have so employees Thee 8wi. aaetor bsw t. Q nonsoWiom
working Aar eta is tray capacity. waken'Camp its ssocs.
(No workerm'Camp:loamsaoe 1. Q We err a cwpaadar and is 9. Q Bonding Adman
3.01 b meowmr o�have mtords"their 10•Q MWWx l rpsir a addldoss
doing all work right of e:mnpdas per MGL I t.❑Phtmbisg repair or add dous
myself(No worker,'wmp a. 1J2.;1(41 and we have so 12.[3 hoof rpair
ins ]t employaa(No waskss' 13.Q Odse
*AM ApplawssIdwho box at Mod also 0 cot drs"maalowaMols�tldr�p�. ]
Nmrewao TASMAM&*kalsdaakadkW%doan garoOdtml�mtiagtaWm�a�sem ya
tCaa6adtwaThatd"rWtasamoisAWmaddmoodshotdoriesAarmoafAotrekemNumaMid aakem ld taasaAs
f ewwodoaa &W&ProviAWs workers'C*MP l SN&g latu►amr*for Ace aAy/oyeas R&*W 6 tkeooBryr aw/fai afar
Insurance Company Name %�ry t S r` t t
Policy N or Self-ins.Lie.N:__- C) != r C, Expiration Data:
Job Site Addraa
Attack It copy d the worker'compoaadon po ft declandu pap(thawing the poBey somber mad apk%dom dace).
Faihue to sum covenp L requited under section 21A of MOL a. 112 can lad to the*Qdi iaa of eriminai pesattles of s
fine up to S 1,100.00 alWar one-year imprisonment,is well as civil peoalda in the form of s STOP WORK ORDER and a Ate
of up to 5210.00 A.day against the violator. Ba advised tlyt a copy of tbia astemeat may be forwarded to the Office lnvcstigadoat of the DU for insurance covetap vai&Adoeof
/do kriebP ceragjr anCer tbOofiat alder o/par/ury diet As im/onsaAm Provided above L ow as corned
Date
OQlelat um only Do mot wrho In tMr errs to be completed by chy of tow o,Qltki
City or Tows Permltll leeau N
lssuing Authority(circle oat):
1. Board of Health 2(circle
I Department J.CltyfTows Clerk 4. Electrical Inspector S.Plumbing la;peetor
ti Other
Contact Person
_ Phase N:_.
PUBLIC PROPERTY
DEPARTtiIE1VT
M.%QWALSV o
&Urx YAwaast„S 01970
lti MT4S•9S".FAX 97e.740.960
APPLICATION FOR THE REPAIR. RENOYATION CONSTRUCTIOI&
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BU1tLDIN
1.0 SITE INFORMATION
Location Name: Building;
— _ Progeny Address:_
J A I'c,.vsc,� C Asti
Property Is beefed In a:conseroadon Ares YM_L( 1 HW"Ic ObMct YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
i ,
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN fwasmma BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per Floor(sQ Renovated
construction or renovation
of existing building New
&d Description of Proposed Work: is r
_ -I��Ar3vily w�.g• �i 9'?�
Mail Permit to: