184 LORING AVE - BUILDING INSPECTION �� PUBLIC PROPERTY
DEPr1RTVIE,�iT
KI%QWJ M ORLWAXJ
MAYOR 130 WAO*NG- M bl if=•&ura4 MAMCHLstlls 01970
TEL MUS-M*FA1c 976.740.9M6
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: N t:_ Building:
-- Property -
012 vJb Ally
Properly Is located in a:Conservation Ares Y/N IMP Historic District Y/N l� _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land w
Name: Q,6
Address:
lp
/kcc� y,11 ko
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISI'Mra BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (SO Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work: 70 s7a�P �XilIU6 /llial� �UiS oxJ /
APPL,YM4) 7W04fiV21 lct w�Ttz sH�fco, D2/P�O6� Al4-W/4// 30 y40--
A-Ptlf,7kcT koof Apil) txm- VAW7-, ASAUZ #'; we/- ' }i arnp
----Mail Permit to: Flo �aer� f�li l� LD Sr�?t�/rl
What is the current use of the Building?
Material of Building? IdJC7C�fl If dwelling, how m Asbestos?
any un'ds?_ _—
win the Building Conform to Law? -
Arch"as Name
Address and Phone l j
Mechanic's Name
Address and Phone G 6�2
ConsbvoUon Supervisors License# HIC Registration#
Estimated Caet of Project S Permit Fee Calculation
Permit Fes S estimated Cost X$7/51000 Residential
Estimated Cost X$11/$1000 Commercial---
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
spectications. Signed under penalty of perjury
Date
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
cnt.rttsT nat9oot t -
YAYM 130VA4m=MSTSUT.ULIKMAXA0a7s M01970
Tara 9W45.9993 a FAX 9W40.9M
Woritera'Compeusadon Insuraaa AAldavW Bn9den/COntrat
Annikant Infermadou
Name l IA►Uly+ (�t C�J ('n�ttCt9cTo12S
Addmsf:__ S5�• WIRL' 1C 61 '
cityiseue/z;p:
A�n y�°ao employer!cbsc r the appropriate boat
1.LIO I an a employer with 3 _ 4. ❑ I am a gong cemsector and I Ty"of mod(rs"kvk
emplayem d(69 andlar pw"=),e haw hi the n & ❑Now comegnedun
2.❑ 1 am a Iola pmpriams,or PMUM6 Hood as the attached theft t y. ❑Remodeling
ship and have no employer '!best ab omhaemo have R ❑DeotoHtion
working tar me In any capacity. warkers'cam}ioamaon.
Din workers'camp ionuanee S. ❑ We An a corporation and its 9. ❑Building addition
) ofikers have eaan ided their 10.0 Ekctripl repairs or addWaea
3.❑ I am a homeowner doing an wont right of exemption par Tit($ 11.O Phizabing repairs or additions
mysex We wait='cow o. ls;41(4),and we love no 12.0 Raofrepaits
ww+rance requited)t emPlayeea ik woricma' 13.❑Other
camp human"regtdd)
;M wee••urn draw ben at ems dr®w us o°daa bdtw dtewy d—k*saints'
itmpwaeMa°vLYdtiralad.vitf°dfud�imrYwedrtgaswatt and else
dwadiarre�rq� 0
tCaeswetesdrtdhak MMMMMMMMM batmtrheWrtlditlaWdretdnwlradrnwrderraYerrretosdtMkwoAra•*NEW
�ador�derbonrvll�werRore'eewawrsdowGrauwaeolirsrpo+'PbYon ddotrbWoo/k>aJJair6Y
Insurance Company Namr__ 1-r�3f 27� f t1(Irl/bL
Policy d or Self-iea.Lia �N'__f Expiration�. y /,
Job site Addreae_ / ui2t ill, AVE Ciry�StaoerLip��L L
Attach•ropy,of the werkan°eootpewtloa`poBey declension pap(showing the policy another,tad exPhratlon ders)v
f1du a to sftwv eoverag,ar requited under Section 23A of MOL of the Dup to S1,J o. 152 can lead to the
fi impoaitiaa of crimiaai Panama oft
of up to ne 00.00 and/or one-yea imp as well as civil paealtiaf is the farm iOf ma STOP WORK ORDER and a Ate
fnvesti f230.00•day against the violator. r Of advised tint a copy or"statement may be forwarded to the OAlae of
gatiowa U far inaunoco coverageveri}Iption,
Edskmd"SOY cord# ender tie wet powo!!br ojpor/wry tbatt/4 bs/ersrdow Pep,"above Is uw ad eorrrd
a0
offle d AM ow/Jt 00 ear ware to sib arr4 to be compkiad Jay city ortotrw OBIciaL
City or TOwa: Permlt/Lleease e
Issuing Authority(circle oat):
i. Board of Health 2 Building Department 3.City
t;.Other frown Clerk 4.Electrical Inspector S.Plumbing Inspector
Contact Person: Phone M:
Lwzzo
Information ana ins>tr v�wOn MMwA fa fig
1�fassscbusens Generd Laws chMM i 32 requites a..amp in 60 "via of another maw any conaad of bite.
putwant to Ibis smarm.as g*op'w is defined as ...every Pea
"*moat unplud-and at •
assoeiatiaa.wtporatiaa as°�legd�'ac any two ar mar
*wVjsYwto ds6ned""aa i�ividual,pstCauahtP vea ota deceased MPWYu-or the
otthethtt foregoing Mpf°d in 910W wWPrtar:a"10��leWl
p.puuwnlqaaodadoa of ather>�entity-�ay'ft e�l°yOOr liovraysr the
teaiver or ontsms°�!w��Inaft rhea andm to do oWMMW% VAO s+To ar npa�`radt as sA d�he°w
dw d wu&w vhr®Pl°l�s stteh emplayarent bs deaamd to be w mipbyar.'
a on the grounds ar
MCd.ah0w 152.12=6)ahto stemsape that" eatulrud bWWbW is tw ees>•aawaah fw w0Mw�
naevfl ate aN is a,Maw etemplauft vW tM b wrsaa es! fo s6aLL
; Paso prates Dlaitbe the oommaaweahh°°r any ahte ptshtieal with thr inaasoa
_ wdditlamuy.Mcii.dsvuas 1s2.42sC1n - -- - ondmadwmPlls - --on
Ww am of this havebift p scowd to the Caoneedeg authority
APpasab affidavit wmplatdy by chedeng the bona that APOYcLw taPft Yawsv*s andw ssd.
W=w y" s s).sddtw (Lim)oe L bft '1�iLL )wiwno _ odw thsa the
taemb�as p�asL aft as te4�to eed d w d&a'caa be m the D"M m m 1aW
wloyses-a poft is i advised that &s s b sip sad dam dw anU&AL MW agWwk s WW
M�m rya mwa" dr da ` = ify *` moabmia a
Idol AeCideats Shotdd Y w M"r wY qw n IIamd below. SWf-Wmvd should enter thais
compenssdw poly pleaw Call the Depsum s line.
self-bsamasoa llrtoss mtttsbat as rite
C"or Taws Omdals
frma otat the bottom
Plea"b.nee that the affidavit is twmpleta ,th printed ldjuve The Depattm o chas a youed s ding
of flu MWsvit for You O fin out in the event du 0131a of lnvestipnau he O eAn w you in adM the an "
which will be used as a refermee ttnmbet ht addition,m applicant
Please be sea to fill in the p liatio"in my grvm year-need only submit one affidavit indicating current
that moat mama ntuhiple paw�
and under Job site Addtwe the appliaat should write"all wa be is_--��a
Po1WY.A copdo° Mneeeauy) at mat W by the city a Own may bs provided m du
UW "A copy d the affidavit that it been offie&is& �te a i A ww&M&vu=W bs MW out each
appliant a that a valid affidavit a license as P� to or cammeatsl vessttr
yeas.W hue a hams owner sr eititxa is obtsising not re 10 coMlem thisdsviL
(i.s. a dog liceoa ar permit m bum leaves cm.)aid pesos is NOT mph"co
would like O thank yes is advaoa for your cooperation and should You have any 4�ip°s'
The Offiu alluveW Wiom
please do oat hesium give us a cal
Ths Dienes addmsl6 mlephow and fin mtmbor
Thg Commonwedth t>tMM&chUSCW
Okla uMd Aoaldentg
Offla t>t�Iavadptio>v
600 washloPa Saeat
Boston,MA 02111
TeL#617-727-4900 cd 406 of 1-8n-hASSAFg
Fix 6 617-727-7749
Revised 5-26-0S WWwjwss pv/dil
f 'h
Crry OF SALEM
PUBLIC PROPERTY
DEPARTMENT
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