106 LEACH ST - BUILDING INSPECTION ' PUBLIC PROPERTY
DEPARTMEINT
KI.%QIMUZ f 13RLSCOU v
S(nvot 120 WAsi IuNa"h r&Fzr "m.LK MtitAon;ttl'rs 01970
To.:97&71S-9S9S*FNt:975.740.98" '
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: ID& Le" St• 41:7 Building:
Property-Address -- — '- —
I Db Lerw1� St z
Property Is located In a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: S-t ue Ted r. ♦v{a� ad
Address:
{0(, L*kc- rod. :ttZ
Telephone: '51 g 352 5wo
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 (sf) Renovated
construction or renovation
of existing building New
Bdd Description of Proposed Work:
b yt U r,tw wA✓N� k^ rq.tst"J W(V,8 w
wtr,&aw r5 ' dovb\e t bk �^^ti - nPw wtrdow 1v
bk ► Spy��:
-- Mail Permit to: < 096V h C It v I� �t�� MA Dl°IZl
o� -----
What is the current use of the Building?
Material of Building? �^)� If dwelling.how many units? 3
Will the Building Conform to Law? _ Asbestos?
Architect's Name
Address and Phone
Mechanic's Name c�oua C• MozErTt ntA D1k21 g139• 352.51+(.5
Address and Phone
Construction Supervisors License# 69q-*rZ5 HIC Registration#
Estimated Cost of Project$ I 50D . Do permit Fee Calculatbn
Estimated Cost X$71$1000 Residential
Permit Fee$
— --. — — Estimated Cost X$11/$1000 Commercial ------- - ---An Additional$6.00 is added as an i
Administrative charge.
I
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 ild to the ove stated
specifications. Signed under penalty of perjury X
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
LAYM 120 VA5Fa=MSew W•UUM4 Ma VXMW ts01970
Worlian, Comptuation Insuraata Affidavit: RogdoWContrae
Applicant IuNrmadom
Plum-Print Legibly
Name l tADeEr, Sukvt E.es
Addmw:_ Cln"ttr ?4Aj-J
City/3tatol * Bkzia WL _ D1 R 21 Phoned{: 9-18 - SSZ- S�( 5 ---- --
An your an ei piow Check spolopr1aft bon
1,91 s a a employer with 4. ❑1 sm a unseal comma r end I Type of Proles(r'e9rd�Nk
amployea OU andlar I• have hired the auQeootraeone & ❑New cmmttedo■
2.131 1 sm a cola proprietor ar pnmeo- listed an the attached sheet t 7.,101amodsling
ship and have no employees Thews wdoomeetas haw L ❑Demolition
working tar me k any capacity. waken'COMP m■■asp,,
(No wodters'comp,insetraneo S. ❑ We an a corporation and ite 9. 13 Building addidon
coqukv&j officers have=Wd"d&we lo.13 Elechicsl mpain or additions
3.[31 am a homeownsr doing a9 work right of earroptim per MCIL 11.13 Phrmbiog tepsin or addldow
mysell[No wordlues,camp. a. 152.11(4).end TA have insurance��t ��a.(DID wadmm' no 12 Q Roof to pens
camp,manna l 13.[]Other
;ANY wvas nr dmb sea St met an AN out Me aaetlo•tdow rbeetat tbi aedraY
Ac,w..e WAS sWWokweeadwilbdeades day ande+gd we*red 60No cad
orea ■�.�r�O
Amararoe.era *We bm muss reedut a adadser stem etr.iee
aabeeatraoem atl msir walow-mmF potty b owner.
Im
law a1■t b worAers'tewptarelsur/aatraaea/ernay mgP/oy■a da/aw b s11 pock)andjob slob
Insurance Company]N=w.. TD
Policy 0 at Self-ins.Lin.t} W E IN l�D-D
G Eap■atim
Job site Add<en 10&, (.raft, St• lt 2
Attach a of tfy lt%u
�W workers'cons ■psafaNs Pegsy declaration Wgs(showing the Polls!urosber and tuptratlour date).
Failur's te Secure eovesgs as spited under Section 25A of MOL a. 152 ram lad te the fine im up to 31.300.00 andior me-year impdoonmR a ivil ea wall as c penalties in the f podtiour of a timiasl penalties of
am im ti s
of up to 32S0.00 a day against the violator. go advisW that s copy of this statement may f forwarded to the s STOP WORK O RDElRDER Ana
and
InvcWV tiom of the DIA lbr inswunce coverage verificatioa
Offlog of
I do Aenby a radar MR&W andpawo/Nee olPa/rry Are At Gr/orsedo■pnae'/&/abort IS Arm a"eoiroea
n 29 o,
Phone M: lc7
B 3Q— s#Gs
FIssuing
o■IL Ge sop write/a fA&area,to be eoarpktad by ells or fawn q Cid
n: PeraWLleeass fk
hority(circle one):
Health 2.BuUding Department 3.Cltylfowa Clerk 4. Blectrlcal inspector S.Plumbing Inspector
.
Contact Perm■: Phone At:
information ann.1n5tru%;"%Y"J
cncgd Laws chapter _ COVWym w Pads was•campaniadon fa dleir MOGYCn.
tusens r' �y�gyp is defined as...AVMpawnP ° ser
vice rvice o[another uodar any othice.
=p'Cee ar UvhA and ar Wnuou.-
assotiadea, a°the 1e01 aary.a my two at mar
An is defined d"an iodivid AL P>�'w td 1t 0►mpra�"a otf decried emPl •or the
of"fosegang en¢OOd iO sO assodadoa ar othar kph entuy.employing emP(Oy0°r Ilowawr the
giver a aueme of m iodividw%paemeeM06 sibs resides ehseeiat.ar the ootaVA atdw
boast having mt mar ebsa dim sperunwo at unfit oa met dwelling bean
a[dwaftaypya morter vbs empbYs 1� be dtamed m be as®PIO
or on des g�ar buDdint wed samubtarmy_ _
MaL ahapeir 1st.}tsC(,alas trams e�b'O'eemmi wW r Lsr saw
rebwal at of is poli"sab*Wslow
e� idtwd e��"Wpub pep of Mouses VAO the Vars� ��ed'
'Pruesm danattY•b(OI.ehsPser 1st.42sC(ni�s0 �uvA�dmcomnkaaweI �of
nt &gpw ban bift rum"m the comaedag wttartY•- — - - - -
reenesse
Ot*js
Ap�b eheeking eta hoses that apply m year iipudan.s4� .
ell art the wodwe a nambee(s)skeng sat
nocasomyPtah SVOY mbeosnaemr(s s).lea)and pb°°s thm the
wswanci Limited Lial Y vadrms If aa�LLC a LLP don be"
wambea Of WOW
raeprlrod. W advised*at d ats s date tits aflWavGt. The*Wdavit ihoald
be reu oed m do two that spptlaa* rhs POEbg*Of�ifY� tsoabra a& d
Aeaidend, Mwwd you have mY 9wellons ngwd
number Us"below. Self bwx d compmiea>hoald am�
campmadsa poft.PWW eaA ebb Daps as*ASot.
self- er Sanonumbas*A
Chly or Tetea Omdsk s V,st the bottom
Pleas be sure that d►s affl&wit is co.VWw and p�IOOV- The Daparitseot has pin n
of she lAdsvit for you to fill out is fire event the 08ia of ImeidOdane has to ncetad y addition,m ap B"ar
which will be used n a misses ntembet Ta
Please be wn to fill in the pmmiN;cana mtaooYbe m mY a Y r,seed aWy submit one affidavit iudicadng current
that moat xaxa mnlnpU P aPP
HCadam the a Beast should writs"all toadom in__(eery ar
lro>icY ia(armadoa(if necalwy)and under job Sits Addend• h marked by the city a two may be provided m the
town)-A copy of des affidavit first has been ofiieially stamped or licaset A new am&vu must be filled out each
that s valid a@idwit is on fit•fat ilmae pern its busissss or eommaeeiei vasur
applicant sr pbo aweer a 4;Wzm is ohtaising a lieanis a Permit ter rehetad to any
year.Wheel a hams is NOT rogohvd ro eo Wle,this affidavit
(i.e. a dog licm»at Pew to burn lava eia.)laid person
would like to dunk you in advance for year coopwados and should You bave any gad•
.�Office a(lnvcsdpdoee
caL
please do not baitaoa ro ilW us a MWOMWNW
MMMMOMMMMMMOO lephom and fat number
The Dcpsrunanes address'to
'ib CmmwnwCdth of M:saach»setb
Depuftledof Tndtt&iai Aatdeab
ON1a d Iavadsuless
600 WASWnOW Sftd
Boston MA 02111
Teo 0 617-727-4900 Cd 406 of 1-977-MA.SSAFE
Fat 6 617-727-7749
!revised 5-260S wwwawmpv/dish
CITY OF SALEM
PUBLIC PROPERTY
DEPASTMENT
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is s000tdaoos with tM s6uh edtdbs e[dw 3bft Hoildt29CWk 780 CUS tesdas 111.!
ckbdol and dw p mvWkme of 11K$.s,4 0 ads
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:hY wait sbsq bs disOoeed otb s>�b lissessd wsrss dlgossl Ad1tq s,ds0eed b1►t►6t3.s
'17w debris wM be trstwpmoed bpi
(stet atbrsiwl
The debris wilt be disposed of in:
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