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2 MEADOW ST - BUILDING INSPECTION O� 1 ---- PUBLIC PROPERTY DEPARTbIF.1iT �r.M�•��,o+uxuu. MAYoa 120 wASMNGrON S'MFEr 9 "MEK WAAQit:sk'r1S 01970 'R3-97&745-9595*Fex,M740.99" 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: �L, (Y\2 A+�,C C%O 5—1 Building: --- Property is located in a: Conservation Area Y/N Historic Dlsirict Y/N 2.0 OWNERSHIP INFORMATION 2.i Owner of Land _ Name: 7©yv )e Address: I Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation X ZS Number of Stories Renovated Change in Use Np New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Baef Description of Proposed Work: p FE(JrA+(Z v ��' I/ �. (�Ki ACV, F� �do tom'- J'�2JCYu R� ( LAVAµtrv6� Ut tW !Do Lo5 /-Iw �J 1�cvotL5 Mail Permit to: I 1�R2 - - F3�v�t Y0 A4, m i li 7a2 --- — What is the current use of the Building? C) Material of Building? moo O If dwelling, how many units? Will the Building Conform to Law? ✓ Asbestos? (20 Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# 0 3 1773 HIC Registration#dLSo.�3�1 Estimated Cost of Project$ 4 ,�eb Permit Fee Calculation Permit Fee$ 1 Estimated Cost X$7/$1000 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 uild to the abov tated specifications. Signed under penalty of perjury X Date i /v-o7 N o o N O r`v1 `- F °o V `' i CITY OF SALEM �,6C• p31 G�7� PUBLIC PROPRERTY DEPARTII/IENT xnraEstta,r nancot.c MAYoa 120 WASIOCrM STEW a SASEs,MASSA 01970 TM-97L745.9595 a FAX 9M740.M* Worker*' Compensation Insurance Affidavit: Builder*/ContracterLM@cbidana/plombm Appticant Information ii ll 9Ple u �* � Name(Business/Organiauou/Indivi&Wy JO"Yo ^. W 1s�y�, WcIS3,v �c1cLtJfJZS Address: City/StateMp:_ S'Ai�w� i n� - Phone 9,00c� Aoa as employer?Check the appropriate boas Type'am a employer with�_ 4. ❑ I am a Bmenl caohactw and I of pOlea(�0 1: employees(fta and/or past-UM).* have hired the sub-contmctms 6. ❑ ew construction 2.❑ I am a sole proprietor or primes listed the attached shoes t 7. �Ramodeliag ship and have no employees These=&-contractors have 8. [3 Demolition working for me m any espacity. workers'comp,inntrance. (No workers' Comp. inmumm 5. ❑ We are a corporation and its 9. ❑Building addition Rquhv&l oRlcas have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs;or addition myself.[No worker' comp. c. 152,ji(4),and we have no 12.❑Roof repairs insurance required,]t employees.[No workers' 13.❑Other comp insurance required) &Any aPViceos*A docia box al mer afro no os the recdoo bdmr do**th, warltas ltesuoasaae wAs,ueadt nhh aAl emdava aNWhoa dry a dsioa A eadr and des Ww omdde omit euhma nse atlfiWwa zc0am ins Me As*ads tax m snedssd aaddWarl shm ds�nee came ores asnaetos abeootrsswe and ertr wloas'oo f am an employer that Is pro vld/ar worberi'compensation inner aecejor my earPloy• 7ejormadow C es, Below is the po&y and job site Insurance Company Name:(S QA yV ITS J?A') '11, N'3 (r Policy#or Self-ins.Lic.#:_ LV L-° FS 7 L f C le Q Expiration Date: /a� 31AS Job Site Address: 9 mS1WoLJ 25'7'. Ci /S ty tawzip: 5'a -F-� rnA Attach a copy of this workers'compensation policy declaration pap(shower* the Failure m secure covers as g l?oBeY number and expdraden dabs a° requited under Section ISA oPMGL a I52 can lead to the imposition of criminal fine up m$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of r STOP WORK ORDER 1pens amend of fine of up to$250.00 a day Against the violator. Be advised that a copy of this as'a thnt may be forwarded m rice OtRu of Investigations of the DIA for insurance coverage verification /do hereby terrify der fist and pan ojperjary Chet the jajormodoe provided above Is bw and correct O—0 7 Official ate oe/A 00 not write be ihb area,to be completed by e4 of Own offlelal City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector S.Plumbing Inspector &Other Contact Person: Pdone#• Information and Instructions _ tar 152 all employers m provide workers'compensation for their ct o fhi e ` ass pursuant to this statute.an chapter is defined as"...every person to the service of another undo any conaad of hire express or impliA oral or written-" as"an indivirind-Partnership"�O�On'�O6�other legal esehr,or any two a more An satpfoYgo is defined vcs of a deceased emPtoYer,or the of the foregoing engaged is a joint Vi"enterprise,and monad ni r legal eats However the association or other ledal entity,employing menploy of true owner o or trusteedwells g boom��than three apartments and or�W' at die OCCUPSM wodr on such dwellms lroua owner of a dwellingf genthor who empioys persons to do maummaWA bed m be en empbyar• dwelling 1100"w t°�err buildiai sppuc�a��esn shell nor beaus°°f such employment or On the grounds 132.g2SC(6l )also states that"every state or local geensing agency shd withhold the issuance or MGL chapter pars"a business or to construct buildings in the c°mm°awu"for sq notaccept"evidence of CamPliaaa wit!the inenrento coverage regniscd•w renewal ad a neeaat O<permie t0 e aAdpdi�tioonallly MGL Prod S�2SC(7)states"Neither the commonwealth nor any of its Political subdivisions shall o[public waft until acceptable evidence of compliance with the inaursneo enter ere any of dus c for the performancepre to the contracting auth" w requirements of this chapter bave bees presented ApPikants Please fill out the workers• compensation affidavit completely,by checloaft the boxes that apply to yaw sitaaon'Dd•if necessary,supply sub-c°OcractOr(s)name(s).address(a)and phone number(s)along with their cetti8cam(s)of than the Limited Liability Companies(LLL7 or Limited Liability Partnershipsi .(If aPn)�a LLP does have are not required to carry worker compensation insnrarmca. members a parle i Be advised that this affidavit may be submitted m the Department of bmdidavit cmplayal ecs a Polley is re9mu coverage. Anse be stun to sign and date the afIIdavit The affidavit should Accidents for confirmation of inairance m licence is being requested,sot the Department of be returned to the city or town that the application for the permit to obtain a workers' Industrial Accidents. Should you have any quesd t e number the law lo if sa are required compensation policy p�call the Department Istms�number Band below. Salt insured campanile abound enter their self-inamana ileums°nmenber on the City or Town O@lefati space st the bottom Complete and printed legibly. The Department has provided a Please be sera that the affidavit is comp gati to has contact you regarding the applicant. of tha affidavit for you to fill out in the event the Office of Invesd Please be sure m fill in tho peroutftense number which will be used as a reference number. In addition, is applicant applications in any given year,need only submit one affidavit indicating ctmrsear that must submit multiple permitlliccme pots inftxmation(S oaasary)and under"Job Site Address"the a should se"all locations in-----(City hent marked by the city a town may be provided m the town)."A copy of the affidavit that has been officially stamped or licenses. A now af"-&Yu must be filled out each applicant proof that a valid affidavit is on file for Morelicense a permit permits pemit not related to any business a commetcW ventureyear.Where a home owner a citizen is obtaining a (i.e. a dog license or Permit to burn leaves am.)said person is NOT required to complete this affidavit The OW of levesdgations would Hke to thank you in advatica fa your cooperation and should you have any quatioN. please do not hesitate to give us a all. The Department's address.telephone and fax number. The Commenwealth of 1ylawachuseps Department of Industsid Accidents Ofdes d Invadplions 600 was 11119 n sweat BosU^MA 02111 Tel. #617-727-4900 Wd 406 of 1-877-MASSAFB Fax N 617-727-7749 Revised 5-26.05 WWWx18M&0V/tile GTTY OP SALEM PUBLIC PROPERTY DFPARTUENT w,�. �s/.eamsoK>rn�.smo�xm.oa�+sot+as cam&ucdoa Debeb Dfspad AM&v% (esgpicsd at 34 ammudoa sad wad" Ia mosdmos wi&&@ sist!edbias ddw Shea HoildiOG CO ft MOM seedow I MS Odm%ed dwp wAdow dUaL s d4 S 51 SWUNG INN N is 11111106 will dw ooadldsw dial dw d bis melds dsn pis areek"bs disposed o(is s ysopedy!(ceaeod wseM diepoat AdBgt s deQeed by!�.s l u,s tsaa. Thsdehis wiu bs byt lC' 2 o rgpesA�--_ (seer erbnMrl The debris win be disposed of in: C-)Ow 25T22 - (ssms of Pasow ° Z- NN 04- /4 d1z, Lr.awo.dv+�+�as � 1 t —G7 dw