138 NORTH ST - BPA B-07-741-07 ADDEND. TO B592-07 4-,�,-b6N-b tJ K -m • p&,em 1 T -'A- It- D 7 --
EI`I`Y-OF SALEl
PUBLIC PROPERTY
DEPARTMENT
Klmar "13RMCOLL
MAYOR 130 WASMNGTON STREET♦SALEK A%AACHM-1l3 01970
TM-979-74S-959S* FAX 9711-740.9U6
APPLICATION FOR THE REPAM RENOVATION CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: , Pe cl 0, Building:
Property Address:
/3CO- Via(
property is located in a:Conservation Area Y/N_,p4,,L Historic District Y/N—dL
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: _A., fi
Address:
Telephone: 45k
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
86-1 Description of Proposed Work: 'Alp,") . iv�g, s ,�"GaAa,2
-- —_ Mail Permit to. a l7D
What is the current use of the Building? 2 /
Material of Building? I✓oa4 if dwelling, how many units?Will the Building Conform to Law? V 2 S Asbestos?
Architect's Name ti
Address and Phor Al ( 1
Mechanic's Name fj
Address and Phone 41
Construction Supervisors License# HIC Registration# /5--3 2 i
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ '23�U Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $6.00 it 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 e 7
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
XMIMA•••,Datscou
MAYca 120 mAam%- OM STaW e SAtEst,11LAWCtttJSErr$01970
TEL-9M745•9S9S a FAX-9M740.9846
Workers' Compensation Insurance Affidavit: Buiidera/ContractorsMectricians/plumben
Aooticant Information Print Legibly
Name lllusioesUOrpaiauon/btdividual):
Address:
City/State/Zip: Phone
Are you se emPloyerT Check the appropriate boat
1.❑ 1 am a employer with 4. ❑ I am a i1 1 contractor and ir7. O
of project(required):
employees(&H and/or part tb=).• have hired the sub-contractorsNew construction
2.❑ I am a sole prapeietoe or partner- listed on the attached sheaf= Remodelingship and have no employees These aubcOntraamra have Demolitionworking for me in any capacity. workers'comp.imarrance, a[No workers'comp iasusnce 3. ❑ We are s comp. insu and itsBuildin additionrequired.] offices have exercised their . Electrical repairs or additions
3.❑ I am a homeowner doing aB work right of exemption per MOL 11.❑Plumbing repair or additions
myself.[No workers' comp. c. 132,j1(41 and we have no
insurance required.]t employees,[No workers' 12.❑Roof repairs
comp.insurance required.] 13.❑Other
'Any w9cong cur deeb box of man s cbedc s4o tin our the seetlae 6dow showing thsk wI
HHomeownersHomeownersw arena this tl 4t aumNutleseed a5sy w doing so war sad Aes We sores ceasaeton am�
insoundea
reana.eta ie aibmb s aw seWsvk a a.t eh tors tux auW m sddltlenal stnet nbwiag ft now of ihn 'ud
n and drtr warlome•aanp.weer ief6ea.eaa
/an am employer that Isprovidin;workers'compensadon iaeoraneajoi my sespleyees, Below/s thepg&7 and fob shin
tnjarmatfow,
Insurance Company Name:
Policy M or Self-ins. Lie. r Expiration Date:
Job Site Address: City/State/Zip:
Attach a Copy of the workers'compensation Polley declaration page(showing the pollry number and axpiraftoa dab).
Failure to secure coverage as required under Section 23A of MGL c. 132 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER sad a time
of up to 5250.00 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 certifjr an tha pains and penaldes ojper/ttry that the injormadon provided above is dw and comae,
Signature,
Date
Phone 0:
official use only,::a
to be completed by city or town ofJielaL
City or Town: Permli/License M
Issuing Authority1. Board of Healtt 3.City/rown Clerk 4. Electrical Inspector 3. Plumbing Inspector
6.Other
Contact Person: Phone tb
Information and instructions n for their MVIOYNL
Massachusetts General Laws chapter 152 requires all employers to provide the serviceworks as OmP undo any contact of hue+
cnsatiO
Pursuant to this statute.an employee is defined an .every Person
in expects Of implied,oral or written."
��corporation or other legal entity.Or any two or more
An employer is defined as"an individual.pattserslup, van of a deceased employer.at the
of the foKlpina engafled in a joint enterprise.sod mcitudtng the kgai However thQ
receiver or eetustan of an n&'vtduaL pumasiuP.association at other legal entity.employing employees. of the
Vartmente and who residue therein.Or the occupant
owner of a dwelling boom havift not °than three
upon or repair wort on such dwelling boom
dwelling boom of another who emplOYs Persona be deemed to be an emPIOyer."
or on the tFO11O�
at building appurtenant thaew shall not because of such employment
that"every state or local drug agency shag w►thbold the Issuance Or
MGL chapter 112.¢ or pa also s�te a b��to construct buildings Is tbs cOn menwealth far any
not produced acceptable evidence et anmpgasan wltb the inattcence coverage required."
Kaawal of•tleenst or permit to 0
BPP�sni wM�chapter soma"Neither the commonwealth nor any of,ita pOfitical subdivisions shall
AdditionsllY. 132.$2 Man le evidence of compliance with the insuuance
enter into any contact for the perfOrmsncs of public work until acceptable
uucoMIX of this chapter have been preeented.to.the coptracting,,awhorrtY•"
Applicants
Please fill out the workers'Oompmsatioa affidavit completely,by chocking the boxes that apply to Your situation sad.it
r(s)name(a).addreu(es)and phone number(s)along with their can8esu(s)of
necessary.supply! with no employees other than the
insurance. Limited Liability Companies(Ll C)or Limited Liability Partnerships(LLih
members or Pancras6 arm not required to carry workers'congmuadau insurance' If an LLC LLP does have
employees.a policy is required. Be advised that this affidavit may be submitted to the Department Of Industrial
Accidents for confirmation of instance coverage. Alan be sure to sign and date the anldavlt. The affidavit Should
application for the permit or license is being requested'not the Department
Of
be returned to the city or town that the tie or it you are required to obtain a workers'
Industrial Acoidarts. Shard you have any questions regarding their
compensation Policy Planes Call the Department s the. number listed below. Self-insured oompan W should curter
self-insurecog license number on the
City or Town On1daN
red legibly. The Department has Provided a space at the bottom
Please be sate that the affidavit is complete and Prix Y•office of _ applicaM
of the affidavit for you to fill out ttliCeens the see n mber which will be used as aneference number.to contact you In addition, applicant
Please be sure te fill in the perm applications in any given year.need only submit one affidavit indicating current
that count o rbmrt n(i f necessary)
said) ind under
as apP applicant should write"all locations m___(city or
policy information(if necessary)and under"Job Site Adampe the app the City Or town may be provided to the
of the affidavit that has been officially stamped t marked by tY
town)."A copy is on file for tbtuee pamita or licenses. A new afrdavir moat be filled out each
applicant as proof that a valid affidavit• s license tar permit not related to any business or commercial venture
yea.Where a home owner or citizen is obtaining n is NOT required to complete this affidevit.
(i.e. a dog license or Permit to burn leaves etc.)said peso
would like to thank you in advance for your cooperation and should you have any quesdons.
The Office of Investigations
please do not hesitate to give us a call.
The Department's address.telephone and fax number.
The COMMWealth of Massachusetts
Oepuungat of lndtas>tfal Accidents
O®ce of Invadplions
600 Washington Street
Basta%MA 02111
Tel. #617-7274900 en 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.03 wwwmass gav/dia
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PUBLIC PROPF.B'I'Y
DEPA
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