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127 NORTH ST - BUILDING INSPECTION ,� • � Cep -�- ��� 7ITY-OF T PUBLIC PROPERTY DEPARTNIENT v IG.MF.RLEY DRISCOLL MAWA 130 W,WUNG'mN STREET �. 'R7.:97�715-9595*FeY:97s.7�9&I6 APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION v 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 Y Historic Dishict Y/N Al E 2.0 OWNERSHIP INFORMATION ' 6 2.1 Owner of Land ' Name: Pra _ s �zd C �✓v Address: Telephone: 9 Q g r7 y / 1 7 Z4 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing 3 Renovation Number of Stories Renovated Change in Use X Now Demolition Existing G Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Pro/posed/Work: L / " w � l��tGJSi � ni✓w 6n1 rdvr, c� o-..,d o.-.i //G f_ / f}'U1YG Ivy lth E'ir-I b✓ %/r:.J, /�i.... rtr/�e �i�i..7` Mail Permit to: A What is the current use of the Building? If melting,how many units?--- Will the Building Conform to Law? -- Material of Building? wO_°--d Asbestos? y� — )J r J Arct;dect's Name Address and Phone e Mechanic's Name— Address and Phone Construction Supervisors License f/ ©�` °L HIC Registration p Estimated Cost of Project$ t y' d d d," Permit Fee Cal uta m permit Fee S Estimated Cost X$71$1000 Residential C�! Estimated Cost X$11/s1000 Commercial r 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 perjury x Date II 10 i 1 al � N .. ar a > o '� 16 -. W Q CrrY OF SALEm PUBLIC PROPERTY DEPARTMENT w � SUVOa 130wwotta mSrmw•smsKVten r1sotvo Mm.M74S9S"•FA1t:9M74o.%4 Construction Debris Disposal Affidavit (required Par all denwlidon aad mwvadm word.) In accordance with the sixth o&dm of dw State Building Code.M CM seetiois 111.5 Debris.and the provisions of MQ.a OA S 5* Building Permit N is issued with the conditim that the debris resulting 5+m this worst shall be disposed of in a properly licensed waste disposal&cility as Mined by M(3L a 1 L 1.S 150A. The debris will be transported by: ��05 Tie (wars a[6suwr) The debris will be disposed of in: (namt of facility 0sn (address of facility) Si o(pamlitapplfcam � o - � 9- ate date ;rtri.rt4r 4 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERIEY DRISCOrL MAYOR 120 WASFmvGTON STREET♦SAr EM.MASSACHUSEM 01970 Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/plumbers Applicant Informatio /� Please n Le 1 Name (BusineWorganiration/Individual): r ra5,p d �� Q � 7 v�s C o / / Address: tj City/State/Zip: �Ji l / 7 Phone #: '2 J?,5 9 111 �2 r7. Fam ployer?Check the appropriate box: ployer with 4. ❑ I am a general contractor and I Type of project(required): s(full and/or part-time).* have hired the sub-contractors 6. ❑New construction le proprietor or partner- listed on the attached sheet. t 7,Remodeling have no employees These sub-contractors have for me in any capacity. workers comp. g. ❑Demolition insurance [No workers' comp. insurance 5. We are a corporation and its 9, 3. �Building addition required.) officers have exercised their 10.0 Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.0 Plumbs myself.[No workers'comp, c. 152.§1(4 and we have no B repairs or additions), insurance required.]♦ employees.[No workers' 1 �Roof repairs comp. insurance required] 13..❑Other I'Any aPPlicAnt that checks box#1 mutt also fi0 out the section below showing their wines compensation policy inti matlas Homeowners who submit this afHdsvit indicating they am doing all work and dim 6ite outside Contrectors that check this box must auwW en additions!sheet shown cone must submit a am affidavit indicating g the uame of the cub-eonnacson ytd their workns'comp.poi kibrundon• !am an employer that!s providing workers'compensation insurance for my employees Below!s the policy and Job site information Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Attach a co - City/State/Zip: copy of the war irr, compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 call lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification !do hereby certify u the pains and pens/ties ojperfary that the information provided above Is true and correct Si a P 7fS 7JO =Other only. Do not writs in this area, to be completed by city or town oQ7clo1 n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector son: Phone#: Information and Instructions Massachusetts General Laws chap Feu employees pursuant to this statute,an employee . ter 152 requires all employers to provide workers' compensation for to a is defined as"...every person in the service of another under any contract of hie, express or implied'oral or written" two or more o rr is defined as"an individual,partnership,association.corporation or other legal entity-employer. alo er,or the An empl Y in a joint enterprise.and including the legal representatives of a deceased rap Y of the foregoing engagedassociation or other legal entity,employing employees. However the receiver or trustee of an individual,p8t1nershi an three apartments and who resides therein,or the occupant of the having not more or repair work on such dwelling house owner of a dwelling houseother who employs persons to do maintenance,construction be deemed to be an employer•" dwelling house of another thereto shall not because of such employment or on the grounds or building appurtenant MGL chapter 152, §25C(6)also states that"every state or local licensing agency stall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings n the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance its coverage required Additionally.MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the instttance resented to contracting authority" requirements of this chapter have been p Applicant the boxes that apply to your situation and,if Please fill out the workers' compensation affidavit completely,by checking supply sub name(s).addres phone number(s) along with rhea certtficate(s)of necessary, upp Y Co anies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the insurance. Limited Liability Companies to carry workers' compensation insurance. If an LLC or LLP does have members or partners.are not required affidavit may be submitted to the Department of Industrial employees.a policy is required. Be advised that this affida Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The Depart it shoal or town that the application for the permit or license is being requested,not the Department of be returited to the city ations regarding the law or if you are required to obtain a workers' You have any quest below. Self-insured companies should enter their Industrial Accidents. Should y Department at the number listed compensation policy.please call the self-insurance license number on the a riate Hot- city or Town Officials Department has provided a space at the bottom Please be sure that the affidavit is complete and theprinted leffice ofgibly. The to contact you regarding the applicant e event of the affidavit for you to fill otmidli in chense numberOwhtch will be used as aInvestigations reerence number- In addition,an applicant Please be sure to fill in the pe lications in any given Year,need only submit cal affidavit indicating ccurrenr that must submit multiple permit/licettse applications Address"the applicant should write"all locations in (City policy information(if necessary)and trader"Job Site aped or marked by the city or town may be provided to the ton:,)."A copy of the affidavit that has been officially stamPe . ^ or liasases. A new affidavit must be filled out each applicant as proof that a valid affidavit is on file fdi`rat:c per-"- t not related to any business or commercial venture year.Where a home owner or citizen is obtaining a license or perms lea this affidavit ea a dog licensee permit to bum leaves ea.)said person is NOT required to comp and should you have any questions, ns would like to thank you in advance for your cooperation The Office of Investigatio please do not hesitate to give us a call. The Department's address.telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents OISes of InvesdWadons 600 Wasbington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mm.gov/dia