323 JEFFERSON AVE - BUILDING INSPECTION �s n.0/sir ffl-ri c-y )
AC
What is the current use of the Building? �i �w unitsT�
T , Fic 4r lt dwelUng,how many
a!of Building
Materi uE J Asbestos? ,
Wig the Building Conform to law?
Architect's Nara ( )
Address and Phone
Mechanic's Name
Address and Phone 6 / HIC Regisbatbn
Construction Supervisors license Z
Estimated Cost of Projsd$ 7 S oo, 0-1-" Permit Fee CalWlatlon
Permit Fee S Estimated Cost X$7/51000 Residential
Estimated Cost X S11/51000 Commercial-_.__ -
- An Additional woo is added as an
Administrative dwge.
Make sure that all fields are properly and legibly written to avoid delays In prooesaing.
The unde f5igrwd does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date 1-116/ Z
of
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A ;life'�pamvM.ana +'.' _p�v .
BOARO OF BUILDI G REGULATID�S
gicense: CONSTRUCTION SUPERVISOR
Mumbei 086200
P S{p�I1981
f Sir�hdake. _ - rn T. ,- �V. 66200
,pi 08101/200 .
Ik CIOd•-c- ��� .. x._
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JOHNE HOWEL .....4
�'14 CHASE$T s Adrdin
" $ALE M MA 0197 ti � ,
°.� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M."YoR 120 WA5111XGi0N SCREET*SAL P\t,MASSACinSL FI5 v19/C
Trt:978.745-9595 # rAX: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 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:
C N60411�r4/ ®vM pji « CO _
---- (name of hauler) 3o ��"� (J der P,ti,r2
The debris will be disposed of in
(name of facility)
. .____ iaddrass of fadliry) .
.. ii��f permit applicant
':ate
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'ImENT
WAVM 1A WAatett M SMW a sun4llAta 0LWM otWo
T&+o W W 0 FAok tt W,*9"
Werkorea Comptta udon I>teuum Alfldavlfk BuffibrSICOWWWrAlftbidauffibudan
A:otleatat ItallisrmtatSem
Plum
Name( o//v /�nwFtc P14 f/n ErC s6i(x� /�Cms�LCc���
Cl pbow
Am YOU as em~Cheek the appreprfap het:
I.❑ I am a empbyw wi16 4. Q I as s paaeal ca&Yasp ad I
empboyan(ta and/or puMma).• be"bind the tL Q aetiae
Near oaesY
2. I am a sob p mpeieew at persm listed an the aatehad ASSL t 7. Q Bemodtlttg
>hip and bow ae employeae lope mboomncloee bow L Q Demo
waiting fir ma in any capacity. wodmW coop,imtnane0.
(Ne wake'comp mswanos 5. Own m a ampondon and is 9. Q anwas add dm
3.01�son a ht maoeraw of lm hew anedaad tide 10.0 8bceseal sepsw or addidans
doing all svorlt eight olaratnptio&low hl�. I I.Q nmd ft mpdm ar add(dom
mystK(Ns werkws•comp, a. 152.f i ft and we have so 12A2DtWrap,ke
i=u mm�]t mpioyaa(No weakens,
13.Q otter
insmenoe ]
�Aaasva••ai@M*Mk bnsnrstsawaarsr&rw.re ispeakaaatss•
He.rearaw bdiabYded.r+aalaly+4rr.aaiyerwrwtemuwanwbo�Maea"Pow drtwenfgaaa
eCe.raarr theNNNWNWN�ark aiYban o itraa.r..eert.erart arrly e•rpsayes rak ears-,N ow ri.mbar ern}MAN tie ndes,
Ilip an My droar do&pre vtd&g WarkaI etwOasrdt&Ge&rt&ee
hvwx wan 1k+wJ'rwi�rea seAon b aktootYej awI/t1 nler
huun m Company Name—C t �r /n/S v2An tR
Policy 0 Or Self--ins.Lie.a
P.xphdao DaW.
Job Site Addeaa 3 Z TCFC �J9• H✓E City/Statea* S�`CEn �+ vR Ol9 7 p
Attack a espy of The woekara'eompe&aado&poncy daclaradea pap(Showing the po ft aaaber tad espfrstlee daft)6
Faihm to secure covenp as required under Saet(oe 25A of blot a 152 can Sind to the
ftne up to 31,5W.00 ampor one.year imprisonment,as wan so cW MWdea in the farm of&S O WORK ER���
of up to$250.00 a day spism the violas' Be advised that a copy of this sotemea may be forwarded to the Ofllee of
Investigations of the DIA for insurance coverap veriflcWQ
l,10 beKIJ CaN�YAdfr lAIOe(ae and penaltlts OfOa�a/y( tbt Ia�orwtBaSOrorl/K abOrf 1.Oat an/et/ryee
7 - 0Y/-0
O,(Jleld list oafyt De art wdtt In Ikk arty,at be eoiepidd by eltf a tits&eQlrld
CI or Tow h 0.
PermfN.kew 1)
Issuing Authority(circle oak
I. Board of Heait► 2. Building Department .1.City/rowa Clerk 4. Electrical Inspector 5.Plumbing Inspector
& Other
Contact Perm&: or.__w
Emt-OFgAi:Et
PUBLIC PROPERTY
DEPARTNIE,�1T
u.a�nsr oyscuu
NAVCX
130 WAsw�S`M=•&M&K X&%ACHLSlTIS 01970
TeL M745.9S9S•FAX M740.9516
APPLICATION FOR THE REPAIR. RENOVATION CO
OC NSTRUCTION
DEyI[OLiTIoI?1, OR CHANGE OF USE OR CUPAN['Y FOR ANY FMSTIN
STRUCTURE OR BUILDugG
1.0 SITE INFORMATION "
Location Name 3 A,6.,e cAlmlcLl Building:
Property Address:- 3 e 3 Te FFE and ACE
Property is bested in a;Conamillon Area YIN Historic Obbl t Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �pNRL�
Name:
Address: z 5 jGf lGnfo + avE
Telephone: g 78
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 NO Renovated
construction or renovation
of existing building New
9def Description of Proposed Work: �T2 r P EX J
/CE `2oof !r� fl/CCf</TCCTM7�9-� 2ao�'
,Slfi^'G C6j t �C ASTDP�f.� 2eo/�/rW DnJ
— -- - -----Mail Permit to: -- _ -