138 NORTH ST - BPA B-07-592 PUBLIC PROPERTY
DEPARTMENT
i:I•%LL4FALEY DR1S[:ULL
MAYOR 120 WASHINGTON h'MET•S"LLK MA,SACHLSETIS 01970
1O-,978-745-959S 4 FAX 97&740.9$"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: —T�n-. Building:
Property Address: 138
Property is located in a;Conservation Area YIN Historic District Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Lano—Fo
Name:
Address: 13 3 AAA 34-
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
S�Cc9nc� 'slcbr /qF+
Mail Permit to:
What is the current use of th Byildinn 7
Material of Building? Ilf dwelling. how many units?
Will the Building Conform to Law? �e 5 Asbestos?
Architect's Name :::v
Address and Phone ( )
Mechanic's Name
Address and Phone��
Construction Supervisors License# Q i sAO G HIC Registration# /152?"r
Estimated Cost of Project o gr yoo Permit Fee Calculation
Permit Fee$ 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 build to the above stated
specifications. Signed under penalty of perjury
Date
of
b N
�' O V
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xne.arttt r attstbtA.
M►roa 12o Ww.vmvGr�av54xlsr•satsss,I/waaaRAYTrstJ1970
TIOU 97W45-9593 .FAX 9W40-9W
Workers' Compemadon Imuranee Affidavit: Buiiders/Con&"tora/El
Anntleant Information Pl sm Paint r e dbly
Namef
Address: 75- CaIc. 5+-
City/Stawmp: -SqI A; I q Phone#: 4z8- I - Ia8B
An VAN an empNyor?Cheek the appropriate bast
1.0 I am a employer with 1_ 4, [31 dor I am a Samoa eom:a and I ��� �( �
employem(fail and/or part-time).• have hired the sub�oaaaoraes & ❑New construction
2.❑ I am a sole peep fccor or partnerw listed on the attached sboet t 7. 13 Remodeling
ship and have no empoyea s Them have S. ❑Demolidm
working for me m any capacity. �wmkas'comp ionuanoei 9. ❑gW�g+ don No waskers'Comp WARUNIce S.
a We am a corporation and ion
tee] of lcaes have eseeeLed their 10.13 Heetried repairs or additions
3.❑ I am a bomeowmr doing an work right of exemption per MOL 11.13 Plymbiug rspaim at
addidona
myssit(No workers'comp. o. 152.I1(4).amid we have no 12. Roof repairs
i"araOCe requited]t CMP�(NO workers' 13.E Other
ComiL Wourance required)
-Aor WHOM art dodo We A mar am an ar�ht tsale ado. horlaa s i6sir.ake.'mopettebe.o twkr Aaa .aa %ft sob"nb tinders"Caner dry a d•ly ds d we sad ore trim aeYt amir•dos ee7t r Wining"
•are tlndasa Idlamit•ssod
lCaasalm art titre ail•are mote rmthte r•ddltlsatt shoo ' Ms ore•di6t tsa aids woeto•'aimP poilm idhemttlsa
'ran an amiyifoyer that/epretdd/mij worftan'eowpemirodomi btsaramicajorary rxp/oyees Brines b W po/le�me//foI afar faljorwatfora
insurance Company Name -YtS� too C r)
Policy#or Solt-ins.Lic.M ion(j131 360 d C P.xpauion Dare - I i-G —
Job Site Addreae 3 C)3 LS j� �{� City/Swan 6�
Attack a copy of the worinn'compewtbmi poBry deetantlsn Page(showing the poBay number amid expiration daft)6
Faihre m secure Covaaga as required under Section 23A of MOL c. 132 can lead b the impositim of atrannai Panama of a
fire up to 31,300.00 and/or ono-year imprisonment•as wall u civil penalties in the form of a STOP WORK ORDEIt and a ffae of up to 3250.00 a day against the vioiasor. Be advised that a copy of this statamem may be forwarded to the Oflue of
Investigations of the DIA ter insurance Coverage vai lkatioo
/do banby rardb d psaalda ojprr/ary dFat tbo lajonnodow provldad abort It&w and comas
S�aTaturo Door 12 C�-,r' o�
4 Ice(58
OJj/e/af site oa/A Do sot write In Ala area,to be coatp/afed by chy o►forw 04k&L
City or Town: Pernslutieense
Issuing Authority(eirck one):
1. Board of Health 2.Building Department 3.CRY/Tows Clark 4. Electrical Inspector S.Plumbing Inspector
Other
Contact Peron: Phone#:
Information and`Iristrucuum
I s2 Mjauea au employers b vrov d.wodtera' compensation fac tbeir employer
Pursuant
u �G Mn^�"�is�as..."M�is the semee of mother under any�o° otl .,
CXVCCM Or MPUA Oral at wntfen."
assoeiuia4 corporation at other legal 'er my two or asore
is defined as"m iadividnsl.pattaaraudR 'ves of a deceased employer•or do
nr a the rapstamt+n
of fa in engaged'in a etatpaiaR including asjoyemHowever the
o[the fnago g L P�'R woodade ,at other legal e»titY.90PIGY1Ofseor of the
_ individual.
of m tiaein.
a tnmsw ache resides
'ver and
owner of a dwaing basso having net°sass thin there apatbtsea wait oa such d Wft hours
dwaftS hogss of smother who ampbYa Posnot because at such sum be demaed to be as MOW-"
at on the g�or building app tw laminas,or
MGi Chapar 152.423C(�alga stow that"such ebb Or leeal l a�ao I &a cooNAWUMMld
K b apnb a bnahsas a<b eesstnd buildiep b fie eensssweaMh far afq
resew"
of a tlesmsa PK� evldamte of OOseprsses wltf tis Imauraaca �° ' shaft
,Pplkaam wbe
is nat Produced atxaPta the commonwealth n t MY of its poll"subdivisions
MGL chspter 132.12SC(7) wait until is evidence o{�pganes with the iasetana
enter into any fthis t for the per bin wo pre presented the contracting au&c t -!'
requ;�eaa of this chapter haw boea pcesmad
ApPtlesnls ,booms the bosses that apply tu Yaw situation and.if
please fill out the workers'co�easadOn affidavit 'by s with their certiIIcata(a)of
s)notn4a).addras(ea)and phone numberO along
L (LLL9 or Lhnwd Liability Patmerships(LLp')with no employees other than the
inualum not requiried ao cant arofims'co�on'�nCO" If an LLC or "J`Wgessubars the Depwu"M Of gal
°ra Policy h Ho advised dust asai t may M1panddab submitted m alLs a s
Accidents�er mn&nsadau of iasutanca eovatags P er Henan is being tequeatu�° DsPartnest a at
be mturnad m ohs city err town That the appHcatron the law of if you are required obtain
Industrial Accidents. Should you have any qusaW na a numa lag
comp��POW Plum call the Depsrun t the
number iiated below. Self-insured companies should mtar that
self- licam tatzabuf as tie _
CKY or TowsOmelsU P��a awe at the bottom
me be e that die affidavit is complow and printed legibly. lime Beans.
of time affidavit for you to fill out in the event the Offiae of Inveatigatioss has to contact You regarding the aPP
Please tat sure m fill in the pamit+hicmaa number which will be used as a reference number. In addition'an aPP�
geadons is any givan yeas,need only submit one affidavit indicating current
that must submit multiple parm►tAice°se aPP
he&MUcant should writs"Ali locations
policy infansatte(if no that
and antler`Job Sim stamped er marited by city err town may err
m the
town)."A caPY of the affidavit teat has beam file forfiy stamped or Jim" A now aa&vu must be filled out each
appliew ss proof that a valid u oar file for 11mne Parma set related to my business err commacisl vamma
ear.Where s home owner err shire is obtaining a license or Permit
(La. a dog license err permit to burn leaves em)said Parana is NOT required m 1C0A this affidavit
would tiles to&=it yen in advance for your cooperation and should you have any qaa+��
The Office of Mvearigations
please do not hesitateto Siva us a call.
The •s address6 telephone and fu number
The COMMweaft Of M=WbnCM
oft &strid Awddlb
Outer of IsvadSR&M
600 WAAMOM Sheaf
Badons MA 02111
TeL #617-7274900 text 406 Of 1-877-MASSAFS
Fu#617-727-7749
ttevised 5-26-05 wwwmas3.&Ov/slier
CITY OF SALEM
PUBLIC PROPERTY
DEPAaTM.riT
Ilk M7464M•PAZ gM74& s+s
Coasuwdos Babtris Dblmat Affidavit
(required!<x�dmOlidas�eeeovsdss woet�
Td aeoo�soss with tM pwAdow � 3M Buildiog Codsy 790 CUR socdm l l t.!
B�� is tssssd�td Omltlles ttlst the darts easultbss fis�.
tld.wort shall bi disposd Otis s Deb iteasd wwo dispod bdft a defined by MOL s
l u.s tea►.
r,e aetse+s Oriu b.tianspoeoed try:
lams dbsrMA
Ttw&bds will be disposed Otin:
(cams o(AailiM
(aJdeam a<ISeiliM
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