39 MOFFATT RD - BUILDING INSPECTION CITY-OF` AL 1
\' PUBLIC PROPERTY
DEPARTMENT �
KI%IBFALEY DRISCDII. 7
MAYOR UV WASHINGTON STREET•SAL F. ,MANSACHLSEIIS 01970
TEL-978-745-9595 0 FAx:978-740-9846 C>n
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: Building:
Property Address:
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ¢ �64—
Address:
Telephone:
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
Brief Description of Proposed Work:
Mail Permit to:
l
What is the current use of the Building? 1\2�2\6 P DAA1
Material of Building? ��+ If dwelling, how many units?
Will the Building Conform to Law? l�Q Asbestos?
Architect's Name
Address and Phone
Mechanic's Name nm 04- _
Address and Phone t Dior f
Construction Supervisors License# HIC Registration#
Estimated Cost of Pr ' ct Permit Fee Calculation
Permit Fee$ i 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 build to the above stated
specifications. Signed under penalty of pedury X��
Date
of
OVI
N
5 9 Y
WWW iZM
l
CITY OF SALEM
r: PUBLIC PROPERTY
DEPARTMENT
KI,GWubr ouscou I W uwxG[ON SIMEa 0 c.L cu Hw+s.�CHLsEM 01970
.tnroa
1m;975-74S-9S9S 1 FAX 973-740.96"
Construction
Debris
patvit
aforall demolitionand ronoanonwork)
with the sixth edition of the State Building Code,780 CMR section l 11.3
la acwrdance resulting
Debris,and the provisions of MGL c 40,S 54:
Building Permit p is issued with the condition that titerdebris
defined by MGL ce
this work shall be disposed of in a propaty licensed waste disposal facility
1 l 1.S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
A (name of facility)
-14(�
(addreae o Pa��luY)
signature of Pu^a applu�
due
I
The-Commonwealth of Massachusetts
Department of Industrial Accidents
(� Office of Investigations
r, 600 Washing-ton Street
== Boston, RIA 02111
www.mass.gov/dig
Workers' Compensation Insurance AffidaNit: Builders/ContractorsTlectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organizationgndividual): �M ,
Address:
Citv/State.,Zip: nc t 9 r:Aty- Phone =: G=l `�Lv:,CJ�l
.are you an employer' Check the appropriate box: Type of project (required):
I. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or pan-time).' have hired the sub-contractors
[..❑ I am, a sole props-Irtor or partner-
listed on the attached sheet. : Remodeling
�
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[-No workers' comp. insurance 5. ❑ We are a corporation and its ]0.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152. §1(4). and we have no 12.17 Roof repairs
insurance required.] t employees.'[No workers' 1- Other
comp. insurance required.]
`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:-
r Homeowners who submit this affida,it indicatine they are doing all work and then hire outside contractors most submit a new affidavit indicating suclL
-Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.police information
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. n
insurance Company Name:
Policy#or Self-ins. Lic. #: \t n og Ct Expiration Date: ?J t—
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI A for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature R Date
Phone 7:� l-2c1- 571 �
I�
Official use only. Do not write in this area, to be completed by city or town official
Citv or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3. City/Towu Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person- Phone#: