127 NORTH ST - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Aanlleant Informaden
Please Met ILUM
Vorne ttbrvncw'Orpairanon/Imbvrhmll: f(�r��i�,.�.o �,�, �,f'"ru��,o GG �
Cityi3tUWziP: al "l'ltcoa N 7 a �/6 S
%rt yam an repbyor?Cbeet the appmptdae boat
Oa atprsJet(rM
1.❑ 1 sea a employee with 4. ❑ 1 an a gmwal t:oolraetor and
2.0. 1` "P, 10(run Anruor p�rNime" have hied the su&curxrsLtem 6. a ion
proprietor or partner. listed a Rom aehselsmd altmet t ?.
sbip and hew no empbyoar rime how II. Q Dernolitim
working foram in any capacity. work«.•ceetp,inmurnnom 9. O BuiMhag addition
No norkmo•comp insurance s. Q We am a corporation aid Its
Nquiradj offices haw exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOIL 11.❑ Plumbing repairs or additions
myself.(No worsen'comp. c. 132.#1(4),mod we have no 12orkW .Q Ruof repein
insurance requirrd J t �mP ituwraosv:a1PIGYcc*.(No wttquin�rl) 13.Q Othw
�,n-rn►rW rbr eb.drs w n west a4o as cur are as s ciao.mxrw riser osrto w.rr,l in Polk.?b kwunaim
tluaaarMwn "A NOW mit u..elda.b�g rby aka doing eg uut sed the h e oes' saareera sr is-WNW a erw almdwb Indinding roam
..Mm asn for chat Ibis ko dmosanoint/an addubr.boa.bowing on Rome star aged rhdt wwbr•m.F Policy w6noo"
f Yat ON tnrpbyer that k prevlding woriters'Ceepprnaradenr buavaaee jor city rntp/ayda BNarr G rim P'rRa? Ywrl/oI x!q
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Insurance Company.4saw —
Policy 0 at Saltine. Lie.M _ .. Eapimson Date:
Job Site Adskese- City/Stawztp.
A132cb is copy of Ib o workers'compensation pulley dmclaralloa pogo(showing the Polley number and aspiration date).
Failure W secure coverage as required under Section 23A of YIGL c. 132 coo lead to rise imposition of criminal penalties of s
rTna up trt SI.500.00 wul/or one-year imprisonrncnt,us well am civil PcnaUiat is the form of a STOP WORK ORDER and s from
nfup 90 S250.00 a Jay alpriast tine violator. Ile advised that a copy urthis stateasum may be i,or%arded to the OIYce of
:.nsamrnns ul'the DIA Cor imurance ;ovcraj:v.:cirieuleun.
/✓Y hrn by r.•rri/j Yn✓f/tit pains and praultlrs Yjprr/ary than/ht lIlfWataNan prowJr/YAow Jr true anal comet
Phr n:e q:
OQ2rid aftYY/jt An saf write is rhdt ores,/a be everpki d Ay r v or/bow op-hd
City of Town: Perrtit/I Jeeess g
bluing Auxhurily (circle one): — —
I. Iluanl of Iltalth 2. Mudding Dapartutcnt J. Citylfoea Clark 4. Mectrical luspcctor S. Plumbing Inspector
6. Other
Gmlact Person: _ Phone q
Information and Instructions
132 requires ertmpkayets to Provide workers' coin for their estpby"t.
G,;ncral Laws chapter all
Pf nu,. huge"tolhi w delbtad"..,A. q person is the sarvire of another under any Contact of hire.
A.rsuagt ro this sterna.an ew�asydd
eaprs"of impt,'A oral at Wittes-
err otter kept entity.or any two at morn
Ate cMpMyer is dsAstl sr ao isd)aidttrtl ptrtrerahs sasx+ .00 C7°��'ves of a deceased employee.or the
of the foregoing engaged is a Jaw saterpria.and ischuft tb, pl ePsose° However the
"swan"at char tepl entiq,satpbyini e1►+P
rocdivtR or nsrsra of a roAividud.Par»oershiprsaid who resides thsrsir,Or the accultm a of the
owner Of a awanias hart hwia f so tmw than dSsa apmdnear walk oa"k dwelling hauls
uls
dweUw%ha of another who employs Persons a do maims'c"n'tr1C°Os or repair
or bttildtet� P �'s0 shstl trot bsastias sf scab eeployamsa bs detawd to be an etnpby«'
or an Thegrounb s
htGL chapter i S2.42SC(6)slay state them""W7 sera se Iced ttScetuint'�y eamrm ad on issamatim r
resawal of a Sam""Peessm is sperass a bashsem K a aetuleset tdldlnp
epPYenat wbe bed sea Pradecd accptaW rnYas"of cO"Pran"wW the Wean"esverage rallak .'
AdditirnaltY.beat chapter I S2,icy)sloes-"Gidta ohs cOorsattwsalth
teat say of its Political atbdtvidoss shall
Performance of public;work until acceptable evident a of casplttrseo with the innranos
ens item„y nnaraa far the to the camrsct>ng mdroeiq•"
requinmenm of this��+bases presented
Applesste
pica" fill Out this workers' caavtnsatim amdavit h'' checking the twtw that sok c st your(s)Often sad it
necessary.supply„rb.cortaractor(s)mmre(st addresQa)and phone number(s)along with their ce eiA Moons of
irtetYartet• Limwd Liability Companies(LLC)or Lisdted L�Pmstrrships(LL>h with m ampbys"other than the
• Wursnes. fit n LLC oe LLP does be"
members or pmmez s+a ��ired. tat this affkkvk may submitted to the Depubnw t of Industrial
employees.s policy y ss of ineausinee coverage. Abe be son to rip and date the aaWaviL The arlldavi should
be return for do curt or to at license is being requested,not the DePmamm Of
be returned to tlr city or town that the appldeatioa Ibr tltt permit the low of if You AN required to_
I omposrl itse pone �call
the
have mquestions number,rc h�below. Self-inwrad eompani"should enter their
corniest" es license
self-inwnoes license ntttsbsr a the aWwrisse
City 4W?O"ORkiab
plea-e,bc,urn I
that the affidavit is complete and printed k:gibh: The popartener t has Provided s speed at the battm&
f tree affidavit for you to fill out in the evem the OfHee of Investigations here to contact you regarding the appliear e.
o
t(th a be sure to till in the ponniulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pormiulicett"applkatioru A any given ycr only should write mit one d affidavit indicating lacarioas __iccily or
policy information lit necessary)and under"Job Slit Address"the applicant
officially stamped or marked by the city or town may be provided to the
town A copy of the affidavit that has been
ils far Ilrture perm 1 v applicant as proof that a valid affidavit is a m related to any bttsineuommer 1 vennut
year. Where a home owner or citizen u obtaining a license or pen
ull one(i.e. a Jog license or permit to Wine lava so.)said Person is NOT required to complete this affidavit.
Ch.; Otii.c of tavestiptiuns would like to thank you in advance for your:ooperation and should you have any questions.
tease Jo nut hesitate to give us a cote.
The Dcpsrtment's address. telephone and fax number:
This Coniatonwealth of Massachusetts
DepouneW of Industrial Accidents
oft*of lfavesdpideM
600 WSSWDVos Street
Boston MA 02111
TeL 0 617-7274900 cal 406 of 1-977-MASSAFE
Pax 0 617-727-7749
2.ia.J 3-26-05 www.mm.gov/dis
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CM OF SM"
PUBLIC PROPRERTY
DEPARTN EM
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Construction Debris Obposof .st"[idsvit
(requimd fw an dm otition and sgtovation watt)
la wcorda»ce with du dxtb edition d dw Stun lltnildin0 Cody.790 CUR section It l.S
o4br*sad dw provisions of MC L a 40.S 54
gWldial;pemk M _ is lum d widt the condition dw the debris resuldnj frees
this worts shall be disposed of in a properly licensed waste disposal facility as defbed by MCA.a
111.3 ISO&
rho debris will be transported by:
�rcSGo
loam of httultd
rho debris]will be disposed of in :
f aauw ut'ixttuy)
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_ — CITY-OF-
PUBLIC PROPERTY
DEPARTMEINT
MAYM 120 W&%HNGWW S UEr SALLJr.NAtSACHIstTIs 01970
TM-97s.74S-9S"•FAx 97s•740.9s46
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: ' 2 /Ups f L 5 Building:
Property Addresr.
Property is kxuded in a; Conservatlon Area YM Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address:
Telephone: '7 g y p
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:
What is the current use of the Building? s
Material of Building? W yd If dwelling, how many units? A /
Will the Building Conform to Law? Asbestos? /t/ U r.1
Architeas Name e
//� < 1 9 K
Address and Phone ,( ` r v tlr fr�a ( 1
/ �
�a
Mechanic's Name .q e/X `�`�/
Address and Phone
Construction Supervisors License# (' HIC Registration# 15
Estimated Cost ct1 P ojq.;I ss Permit Fee Calculation
Permfl Fee i F)��al.� � Estimated Cost X S7/$1000 Residential
Estimated Cost X$11/111000 Commercial
An Additional 55.00 is added as an
Administrative charge.
Make sure that all fields are property 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 perjury X �f
Date l 2 O'7
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