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28 NORMAN ST - BUILDING INSPECTION
J ' • . • ���� '' ' PUBLIC PROPERTY � �' DEPr1R'TbiENT KI>LLIFALEY DR1S1:0�1 � H�roR 1�W,�w�Hcmt+5'�.'[�J.�t'�,�fnsSncH�st�'rs 01970 1Fi 978-74i9595�FNc:97&7i49846 APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION, DEMOLITION OR CAANGE OF USE OR OCCUPANCY. FOR ANY EXISTIIVG STRUCTURE OR BUILDING , 1.0 SITE INFORMATION . Locadon Name: �„ ���„` Building: Property Address: �� n���.. �� s���.- M-� c�w�� r 3 propeKy fs bcated in a;Conservatbn Area Y/N HI Dtatrid Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner ot Land Name: {�a� � ��E�L-�� Address: �--1 • 7lXMl• 5 a- �jt',V ti � Vih�' Telephone: 9�� ' S�`� ' 3� � 3.0 COMPLETE THIS SECTION FOR WORK IN Fx�aT�u� BUILDINGS ONLY Addition Existing � Renovation Number of Stories Renovated � Change in Use x ' NeW � DemoliGon Existing / / Z 5 Approximate year of Area per floor (s� Renovated 1� Z'� construction or renovation New � of existing building !/ 25 9tief Description of Proposed Wo n ��� ���o ��ya/ n_��� ' I� C�,GtvtcjQ C1 SC � �r . �� ( (�f� iYt`�'O � $ToJeSS�ov�o✓� o`T�'GS ��n � VI/�1���Cj �oo.,�. l/ ___ - — Mail Permit to: What is the curcent use of the Buitding? ��� v�` Material of Building9 If dwelling, how many units7 Will the Building Conform to LawT �-�S • Asbestos4 � Archkect's Name Address and Phone ( 1 Mechanic's Name %��� �``{'�`�'''��9°'� Address and Phone Construction Supervisors License# PJ�7SL����' HIC Registration# Estimated Cost of Project$ � '�`� PertnH Fee Calculatlon PermR Fee S� '� EsUmated Cost X$7/51000 Residential EsUmated Cost X$11/51000 Commercial M Addkional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly writte�to avoid delays in processing. The undersigned does hereby apply for a Building Permk to buj d the above ted i specificationa. Signed under penatty of perJury D te — I d � I 0 N e�i j � \ � � � � � ) � r � r ,g .� \ � ` S � � p � � a � 0 .. ` b �, � a � a �. o F" ,u 9 "�°� � o � u � 3 = 0, � L 4 --. ... W -- �- --- o- --_ ar�- --� —. �- - ----- _._ — -- —- -- � -- —. � ' � � CITY OF SALEM , r�. PUBLIC PROPRERTY DEPARTMEiv'I' ��� �Yoa 120��StmuGTON S'n�eeT�S�[,FM.MwWCtn�Rs 01970 7�1:97i74S9S9S �Fex:9747�0.� Woricen' Compen�atlon Iwarance AfHdavih BnllderalContraeton/Eleetr(ctan�/Plnmber� Anoticant Iniormatloe Ple n Name(ausinn+/Or�an;aeodlmiv;eual): __ �F2L��- � .�,/S�'[.r.e.cl�ifs✓ nddress: l ,�L,�G/y ��irs--C� Ciry/Stata/Zip:_��-Ii�9vlA�C �,�1����f� Phone#: rGt`�—��/�-' a3 y � ' An yo empbyer?Cbcek tM ayproprlab bo:s Typ�ot Prol�(�: l. I am a employar with.� 4. Q I am a yenaal eonhactor md 1 ❑ �uctian employea(iWl ralloc paet ame).• have hired the wbcontracton 6. Nea 2.0 I am a aole pmprimoc a p�man liaoed on the aaached+heat f 7. ❑Remodelia� ship aad have no amP1M'�+ T��haw 8. ❑Demolitim worlcin` f�me m any cap�ciry. wockas'comp.inauanw. [r�Wo�.��.� s. p wa�.��a�u 9• �a�ua��.aa�a� reauirad.l ea7cas u.ve mca�eieea thea lo.p Ble�wical reptin or addm�. 3.� I am a homeowner doin`all worlt �B�of�pa MdL I 1.0 Plumbin;roPain or addido�u myaelf.[No wortun'eomp. a IS2,41(4�aod we Lave� 1O�8II���I� �P�oY�INo wodcecs' 12.Q Roofrcpaics �omR innuaoca cequired,j 13.�Othar ��+m�wv��r ce.ek.baa r�mmt ra eu as��eetlas b�b.reo.�mrtr waita.• Hom�oMoa�w�As ru6oY�hb�NW�vb mdkaWy�MY w ddoi�U wadt md A�A�p�ddr em0�eoon mdt w�kok�owr dlld�vY =Cana�ean tldt eheek�h4 bmt mua ameE�d�a�dd(tlaed�hiw�6oalo�tlr��of�ab�eaah�elan aod�hdr�ror6s�'eomR Wb�tloa !a�w aw�niPloya t/�at is provldfnj workin'coaoenratloa lns�nanee or ery en�pfoyres Below b Ny�peye�,o�1Job,dq tajoraratlow, � � Insurance Compauy Name: /;9�/�C� �S Policy�1 or Selt-inr.Lic.M: Expiration Date:_r�-�/- O� -- Job Site Ad�: CitylStatelZip�.�.UO V1�rl�� Aaae6�eopy o[t�woricen'eompenudo�potley deeluado�P�i�(s��tlu potley numEar aad e:pindo�dW�, Failure w xcum coven�e as r����A of MGL c. t 32 can lad to the imyosipon o[crimiaa( fine up w S 1,300.00 and/w one-Yar imp�,wnment,aa well ai civil penaltia in the Porm of a STOP WORK ORDF�,R�a qne of up w f250.00 a dsy againu the violamc Be advised rhat a copy of this statement msy bs focwarded w the Oflice ot Invesrigations ot the DIA for inauraoee eovenge verification, /do kweby sd rh� psna/Wr ojp�r/nry that Nrt in/ornwdow provWed abav�!i arw o�l coriset ��C . _ � . �.� _ jy O,(jfdaf ar�onl�e. Do not wrll�!w rh4 ars;m br eomOlatd bp e/!p a�o,�ClaL Ciry or Towe: Perm(f/Lleen�t N Iuuine Aut6ority(cirele one); 1. Board of Haltb 2.Bufldin�Department 3.Ciry/I'ows Clerk 4.Electrical Inspeetor S.Plum6fn�Impector 6.Other Contact Persoo: Phooe M: �� - — Information and Instructions - �sy�achusem Generst Laws chaptac l32 cequires all employecs w pmvide woricas' compensaaon for their emP1aY� �i w chis smturo.u►a"D�Y�is defined as"...evay pesson��he savice of anod►er unda any concad of Lire. ' ��Iied,oral or wriaeu." express as m individuaL P�°�'�aseaiatiou.wipa+a°°�°�i�°°a�'°t lo a,or ths An�a�ploy�►is defimd �n a oi�� va of a dawad emP Y of the fcc�ioin`en4ried� 1 �'������ ep, Howeva the associaaan a otha[���Y.�P�Y1°i°mP��Y reeeiva or austee of m individus�.Putnas�P �w6o msides�.or ths oa�P�of ths ownat of s dweRin�L��°hsvi++[n�maa tban tbree� �a�w�on auch dael�� dwellini d°�°O° a buildia;sPP���oo shall mt beeauae of such e�P����tO be m empioy�.� �00�� MGL ehaPta�132.42�(6)alao snw thu"evuY stau er beal dee�sf����a W�weak\t�� f0 O�[>b i bW�RQM Or�O tOYh4d���tbt����r�r���w rea�wal ot a tlasa or P� aaeP�abL avidesn ot eomptluc� aubdiviaioos eh�ll ' 'P����rYo 6�s�et Prodtiee� g�«Neid�er ehe eommonwealta mc anY ot�P�litieal qddiumally,MGL cdp�132.$23C(� ���walt until aecepuble evidence of comFlis���the imu:snet • entac into any can4ad for dm p� to ths co�i a��Y•� ��s of this e6�pter�ve been� Ap�"�a me boxe.rhu apv1Y m ywir eimwon en4� ' Ptesea 811 out the wocicm• ��06�vit comP1�1Y.bY��i neceseacY.s�PP1I!�O,°�O�s�°����•ad�ese(a)end Plmm�umbei(e)a��i W wn��P�Y�,'�0f duo ehs inyutance. Liwoed Liab�hey ComP!e�°�R't'�a Limiad Lisbili�Y YatmeretifW(T-1�) w�atsY wodcas•cempmas�°�1°'�i°O°' IY an LLC or LLP doa have ����u��� HO�� AI�M�ar�to sip and dace the affidavlf. 1'hs a�ldsvit ahould pccidena fa wnArnoat�°f�°C°coveraQe. of be roauned w tlbe oity or to.,ra thac che aPvlieaaon for dte ye�mit�liceme is bein�rwuested.nM the Dep� the hw a if yw aze re4wnd to aMain a w�k�s� �d��A��,ptew eall the��Da�s� �n��ti�d below. Self-inwsed com�a��d�� compenwtioa P° ����e m�mber on t6a Ctq or Tov�� e��yo� Please be sure that t6e a�davit is camplete aad prietod tegibly. The Depac4nmt has provided s spae oP the ai�idsvit foc you to fill out in the eveat the 09'ice of inveatigations has w contact you regardin;the applica�. Please be suro co fiU in the permfNicensa number which will be uaed as a ieference number. Ia addido4�aPP�� lications in any�iven year,need only submit one affidsvit indieatia�cu�� that must submit mul��C�P�����Job Site Addres�"the appliesot ahould write"all locaaons in__1��Y� , policy infoimadon C or mariced hY the city�wwn mry be pmvided w ehe wwn)."A copY of t6e aftidsvit.t6at has ban ofHciailY s�a� ot ticwx�. A naw aFud+wu muR be filled out aeh aPQi�cant y proo4 that a valid�aEtidsvit u on file f�t�uae Pemun aa related w any businw a commaoial vanaue yeae.Wheie s home ownac ar citizen is obtainini s iu�°s°°�P� ���leta thit afRdavit (i.e. a do�1'ueaae a pamit co bum lesva e�.)said perwn is NOT required m advauee for ya�r coeperaaon and should You have any q���. 'The Oftice of invesagations would like to thanlc you. please do aot hesitate w give ut s ealL 'Che DePac�°��'addres�.tel�P6one and fa�c aumbae T�0�WCi�t�l Of�SSiCb1lSCta ' �p[Of�v�I�GII�3 Otda of Iavad�[ons 60o w��sa�e �ii�uoziit Tel. #617-n�-a9oo�ao6� 1-$n-Massnr� Fax N 617-727-7749 Ravia�d s•z6-Os www.mest.$�v/dii / CrrY oF Su.E►� ' PUBLIC PROPERIY :, D�nx'r�.tvT �� aluvoa i��w�w�w stmr.s..n.x�o�c�a�e�smn. 'h�:lfL7a3ASf!�F,►�al7i•7�9i1� q_ Construcdot Deb� Dtspo:al AfUdsvit (ee�tui�S�r�n demolidoa aoe e�aovadc.w�alc) I4 uootd�oe�witb th��cdt edido�o[dr Sdoe Bni{die�Cod�780 C!�@ sxt[as I t l.! p��dr p�ov{sia�otMQ.0 44�Sk Buiidtni P�ndt� - i�i�oed witd�ao�ttto�th�t eh�da6rb cawlet��vs �wa�t�aq D�diaoa�ad ot is�peo��►lte�ed w�w di�poa/Adlit�t a�deMed by s[C8.o i u,s 11a�. Th.a�i.�u b.�an�oKee br �r�✓YI���� ` ��� 7'h�dcbris wiU b�dispo�ed o[in: (aaiw o[lheiiit» faJde+�of fheiliry) ! i �n of � , f�- �y-� � . , � ��..x�. • _ � � , i �i I �� : I t _ i ' I _ � �'' . 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