14 MOULTON AVE - BUILDING INSPECTION (2) — cn-y-OF
PUBLIC PROPERTY
' DEPARTMENT
AI\OFJIiEY DRISI:ULL
MAYOR 120 WASHINGTON S`ME T•SALEK MASSACHLSLI-M 01970
741 97 8-7 4S-9S9S*FAx:979-7i0.9846 ^�
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION _ ) C
Location Name: ABuitd(ng:
Property Address: /y S T
Sib�[ii ti LM d
Property is located in a:Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: rse / _QnJG6S c
Address: /C�./ /tjoeGTd A; S7`
Telephone: F 7JO -
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 (so Renovated
construction or renovation //�S�
of existing building New
&ief Description of Proposed Work:
��t�uc.Tv/z-dL ��',a/f2 o•v jfiiE /2i�y� �/2oN7�
Mail Permit to:
A
What is the current use of the Building? L—
Material of Building? /X1<210 If dwelling.how many units?
Will the Building Conform to Law? ���s Asbestos? /V U
Architect's Name CIO G B 5
Address and Phone 1/ k14 P``-<6T
Mechanic's Name�rrr',, F2- �T?�/ i� (mil✓ 601VT
Address and Phone c7—IF2✓��>� {2�
Construction Supervisors License# dZZ `/°6 HIC Registration# /C rx�6 2,
Estimated Cost f Pro $ (f)o Permit Fee Calculation
Permit Fee$ 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 bui abo led
specifications. Signed under penalty of perjury X
Date
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xwsmitav t>tttacat
MAW* tW TASFmveroW Sr W a SAt eM,MA%AQNRTR 01970
TEE-9W43.9395 a FAX 97L709M
Workers' Compensation Insurance Affidavit: Bni[derslContractor Medridanw7hunbera
Applicant Information
se hint r edbly
Name is 7J�r2 ��2t7�7 ��1� �j7
Addreaa:_2S .?z- ,g5,e ✓rd/,E �'��
cityistmemp: mne
An y4a as employer?Check the appropriate best
1. ' I am a asopkiyer with 4. ❑ I cm a general eounseses and I Type of Joe(��.
emPleYea(!W1 amNar Part-time).• have hired the atbeoneraemre 6 13 construction2.❑ I am a role proprietor a pmmao- listed as the attached sheet t 7. Q iemodslinj
ship and bees no employees Them how 8. ❑Demolitias
worldn8 for the in any capacity. workers'comp,insurance.
[No workers'camp.insurance S. ❑ We are a corporation and its 9. ❑Buis addition
regvite&] offices haw exereimd dm* 10•13 Electrical repairs or additions
3.[31 am a homeowner doing all work right otesanption per MOL 11.13 Phunbins repairs or additions
Myself[No workem'comp, a 152.41(4),and we bees no 12.[3 f repairs
]t employees.[No wokaa' Roo
13.❑Roo r
�lonsann requ. - i
;AwY WHCW*M cheeks boa at mat e4o as ae sloe seeder Eder dmsrfer&W waikms'aw�pmowdw policy hsimeeaet Hoorosm wbe submk Mb adidmit"soft mry w daft m wady d dr tdm aiddde easeeews ems erbmit a ew oladark nnlfy ss3.
tCaoeeemse dew cheek slob lore maw mores/m addblond shoo showier the same a/the mkeoeueaos d t k wookim'eemp poft whosedm
iwjermodoa► stint 6ProviAlwt arorhas'eomOrwsaBon berrraweejor cry"'Ployeea ROAM Is Ae po&7 ar/Joi did
Insurance Company Name•. L
Policy w co Self-ins.Lis M W C 2 - 13/S 3 Y6 5 Expiration Darr. CS 7
Job SiteAddrean �y liliieqaL7-0iJ
- cieyisrare2ip:
Attack a copy of the worken'eompeswtlos policy declaration pap(showing the poBey number and esplrados d1b)6
Failure to secure coverep as miuired under Section 23A of MGL a. 132 can lead to the
fine up to 31.500.00"War One-year i imposition o[criminal posu tta of$
impriwmnent,sa well As civil penalties in the form of A STOP WORK ORDER and a Bins
of up to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offfm of
Investigations of the DIA fa' coverage vailicadoo_
/do hereby cent .wsdp' 0JPer/"Y rh*I sloe lnjormadow provide/oboes Is ores awI eorrns
L
Phone M �
O,flcbsf we ombi` 0*wet writ*In All*red,At be complete/by cloy or own q(Jlefid
City or Town: Permlakesse M
issuing Authority(eireis one):
1. Board *(Health L Building Department 3.Cityirow
0.Other a Clerk 0. Electrical inspector S.Plumbing IInspector
Contact Pierson: Phone 0:
Information and lnstrucuuu3
to provide worker'compensation for their employem `
ydayyachuscna General Laws chapter 132 t �PbYC1i contract of hire.
pant to this statute.an satpTmprm
is defhked as"...every person is the service of another under any
express or implied'oval oc writers"
assoclstias.corporation er other legal�'of any two a mere
An e,rP/gysr is refired as"au individual.pa P��the 1,0 rapresse"�of a deceased anployer.or the
of the fotegumg en' d in a Jomt enterprise. tonployn•Mass
of
she
� awbo deride therms.er the oocupsnt of the
deceiver a tntsta of m ind►vidusi.paraaeramp. three spulaseno to do maint�.eaoho reties er depart work an such dwelling borer
onset of a dwelllsg bnsaa�e not
ersteplaysase
adwe� ther VAD' peso shall oat becmas of such be ed to W a empbYer•"
MOL chapter 152.12SC(6)also stater*0""say stab as'iota!Nam"alpacy char chase a es Ifs°ana or
•basisaM or t&comweat brdiddep V than eeMnawgdh far arty
reYwal of a HNn a pnrsdt so mPna wleh ti m is"a res '""'a
aPP�uOt wW bs act Weduced aeeaptabis m"Idasa et mMpgaaa of its poildcal mbdividoes shall
�noaally,MGL chapter 2,#23C(n "14�the commanwshh or Of eOmp�lOa with the"MOO
enter into any contract
tffor ties parforusm"�Pu�"1O�until acceptable
rrgiuramend of Ills chap—have been pcamted W the a�"
APP�ob ch"Wng the boxes dial apply to your situation and'if
plasm fill out the wodwe wtnPmstion affidavit y' numbn(s with their certit3atda)of
�,�y.amply sub•connfeoer(a)name(t).addtm(a+)and phone Perms(AP)with no erspinyea other thas the
iNv<aeq, Limited[,lability C�P!sn(1'�Workers- Lishift inEwswe. If m LLC or LLP dos haw
�or s.a�°c'is Be advised*9 this affidavit MOO be submitte net required 03d to the D Varmens of ludusaiai
employeaa. of ingurance��gs. ALm be s>am to sip anti daa tbm a>�davlR The affidavit sbasld
be returned to the city er town that the application der die�egadiag�law HennifYOU an sequNtA oya a of
Industrial.AaidmM S>nM you have WZY 4nesd0Os t
the Dep
Compensation PO plan all ounas at than mmtbw lisped below. Self mood companis should enterr
self-ioavmce Hose"°ember on the
lief:
City or Town Metals
legibly. The Depermmt has provided s space at the boetens
Please be sure that the affidavit is complete and printed here contact you regarding the applicant,
of the affidavit for you to till out is the event the Office of Tnvstigations
Peas be a m to fill in the permiylicmae number which will be used s a reference member. In addition.ic applicant
se applications in any gives Year,need only stnlsntt one affidavit iadlcatitig cursmt
that menst submit mull under"Job Site Addrod'the applicant should write"all locations is---(city or
1 information( the c or tows may be provided to the
wove}"A copy of the affidavit that has has of3leWly stasnpad it or licenses A new a�vu must be filled out ach
applicaos s proof that a valid affidavit is on file for f der permit
ear.When ahome owner a citizen is obtaining a license or permed ant related to any business or commercial venture
Y imp permit to burn lava am)said person is NOT required to eomPle'this affidavit.
(i.a. s dog er and should you have any qusnous.
The Office of Tsvestigations would like to thank you in advance for your coopwatiou
'dais m
l.
please dosot beer fly us a cal
11, D parneg •s mess.telephone and fax number.
Tee COMMMwe"of Ma+swblum
Dep tau na t of IndnsUW Aeadents
Office of ILvadpldose
600 Watahingtoa Street
Brit%MA 02111
Tel. #617-727-4900 Cd 406 or 1-877-MASSAFR
Fax M 617-727-7749
itcvised 5-26-05 wW WIDMgOV1&
CTTY OF SALEM
PUBLIC PROPE TTY
DEPARTMENT
'w"w'�aa
VOL 9MI454M 0 f ma M7+►rw
Coasimdofs Debris Disposal AAldsvit
(required ibt ail dsm am and maw"
Td aetiatdae�wtd►ftfa f lirvWft Coda;7W OA seetten 111.!
'
$ is tsnsad wift*a eoadt"fkal dw I I I rertddos!horn
fbia wok d"bs dtspoaad of in a prspaft 800asd wasps d WoM 6dlttlt an ddtnsd by bM s
l t 1.31lOJ1.
The debris will be transp Md by:
✓�Y�u,cG
coma
The dcbds will be dispod of In:
(same of IheiliM
u,fm�ut p�ms
dW
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HOBBS ENDEAVOUR CORPORATION Ia ens
84 Rockland Street SHEET NO. OF
Swampscott,Massachusetts 01907 CALCULATED BY w ti DATE 7�
781.581.2454 978.744.4646
p CHECKED BY DATE
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HOBBS ENDEAVOUR CORPORATION f'A
34 Rocldend Street SHEET NO. OF
Swampscott,Massachusetts 01907 K, / G�
781.581.2454 978.744.4646 CALCULATED BY DATE
CHECKED SY DATE
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