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163 North Street
Building Permit Application
Summary
1. Scope of Work
(2) rental units and an owner occupied unit will be converted to condominiums.
Principally, scope of work includes cosmetic repairs that do not change or add to
structure of(3) family building. Cosmetic repairs include installation of new kitchen
and bathroom fixtures. Scope of work also includes placement of "common"
electrical devices on a unique meter and breaker box, as well as installation of hard-
wired smoke detectors.
2. Scope of Building Permit Application
Replacement of floor boards and steps of front porch, which serves as a common
egress for two apartments. Remainder of scope of work is considered cosmetic or
general repairs.
3. Additional Permits
Electrical and plumbing permit applications were previously submitted.
uaparrat'm of inausrnr ACCAOCms
OWN oflnwatddo#ea
9) 600 Wisl fttoa&rest
Boav4MA02111
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Worker Compensadon Inennnee AfWavit: BWMen/Contradora/Etedrkhtntullumbera
Annikant h6madnPkaat htat L.etai6ly
Name r A�(i�c�z � "E
Atlbesa:
Citouv w Q u i w cY ; h`�+4 02.1(09 Phonon 0: C¢ -2 1 Z S b(o L
An yo.u emptgyart Cfeek thr appeeprlste bar Type of preim vgdre).
1.D I a a employer vvidtt 4. D I am a leead caaaaclor and I 6 D New CMWN tioa
(1hg and/or ParhtimW have Hod an as vabocoowbed a ackn
hon 8
2. I aan a aok pmprteler a Parma- Iisled on�aaachad:heat= 7.)@�Remoddmg
shipsodhaveonoemployee Theme aobaonaacausbeve a DDemolition
waldog Alt me fn aq cwa*. WO&OW gyp.,asatsece 9. D guaft sedition
[No woskae'mqp.i 3. O We are s ompmatian add it IO D Eleeaieal or addidoas
offA=have esacitad their t
3.0 I am a h meowinei doing an wok rwo ofeaeaytiM per MOIL 11.13 Plombiod npaaa err a Widow
t> u e. 13$;1(41 and we have no 12.0 Roofrepsks
rm�aoa tegoited] �i INio wodsan' 13.D Omar
ioanaooe raawM&l
•Any gptium art Awlsbsa 01 mat on oia m to®mt err m bd •owlgart wales'mrMmmem pWq t�
t Homowww who mbmitink otfidwk bdmft day Oft A wodt edam Mm:amid.oomatga mot admit a am siadvlt bacadus MA
tCanews m art cbeb d&b=tot tlmad a dditiaod dot obow6e ft�ofo o mb=suwftm and art wot ate oaup6 po"mMmtioa
f sat an emptayo"bs p►avIAW arorbws'ev opatsdlw btsurn w far sw=Wipy s Mew Is Ow pegq sad job sib
Mnsotasoe COMM
Policy#1 or Self-im Lie.aMr E*sadoa Data
Job Site Addles: t�ily/StattlliD.
Attach a Copy of the workwe eompeasdtion po ft declaration Pape(showing the polley number sad ewlradon date}
Fidime to seaae eovemp as regnh ed under Sccdw 2JA ofMGL a 151 Can Ind to the imposidwofahninalpenaltics of a
Ann up to S1,500.00 and/or owyew went,he well as civil peaahies in dic dHm of a STOP WORK ORDER soda Son
of up a S2J0.00 a dry agaimt the violOw. Be advised that a copy ofthk statement maybe foswaded to the Ofte of
Investigstiam of rhea DIA for fi araoce aovaage vaiSadon.
I dp Awwby odpmNNN dPw/wY Ave AN/*wddenOm►bkl above Ata ow andwres
SiEnam �&z Dow
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W 1w Da adf WON ate A& W be� � � cowplsbl y e1d or bsrts apLdi
City or Towns FermliMenae 0
having Awliorky(drele one):
1.Board d Mdeabh 2.Building Departmeat 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.other
Cow"Fawns !hose 0.
C,eacrd Laws dupwr 152 mqukas all a IGYaa b Psovfde w6*as' 0*'V"st�a
pmsuast b
ur ache d this stamfm. an ss�is defined a"..•evay Venom is ma service of aowher under my contted of hire,
espreftt at implied.and Of wriuee." '
aYOea�ftiaR afeporsua at two Of mose
As aaypys a defined as"am individual,paimmhiP. err other decenad��er,or the
of tla ° it s jt►btensaprgs,ad swatios 1� ���by�, However tb
receiver ar uuStes of a•k dividug t" an erg spur us afar d wi Cu*, '- _
owner of a dwelling louse bwiagmt more eras mrea spsstmws and silo teaide fhfda,a em such dweWng home
d�basso of atcdm wlo®Pbya PasDDe b do But became oomana V � ddegue d b be a CMIDYQ"
of as era pounds a buiUM VPa WIM maeSa sing satbccsets of coal tarpbymat
MGL chapter 15%42SQ6)also SOW drat"eva7 stale as load lkaft agese7 sW wlthidd rim lrssum"err
resewd at a heeded or persdt tr apemen a bduae err to eseeirud bdMly In tile comseswuft far MW
oppet"whe ba eel p ERA mPIA aceptaMs evldeset eteemp"M vAM the Iwrnew eorrrap requirW
Adt>;tiosally,MCi.dWW ISL f2sCC>1 stsu s"Name ma comm wed&mr asy of its political xdWM M alai
wet gab serf for me pab®ance ofpablie wont undl asceptsbk evidence otaoetplisnos wim else iesurasot
requir mws of min dpser beve been pond b on come acdsm samodgr."
Affkssb
pease fill out tba wefirem' afiteavk campksdy,by electing efe bolas mat apply b yeer situfstiom and.if
newassy,mppb seb-ea (s)==(,I addras(a)and pbone amobaso)abeg wim malt<atificaee(a)of
i MMM Limited Liabs3f{'Y C=Vdes aM of Lidmd LUft Pumasl a(LLi')with no eMloyese ocher em ors
members of parma not required are n required to cosy wrntes'aampmatiaa If s Id.0 a LL?doe lave
employes,a poft is requhV& Be advised mat mil atidavtt may be submitted se fie Depamnat of lsdoatdal
Accidents for ocofirmattae 4f ioanance eovaaSa Also be sere to nip era/date the didavn. The afidavit sbWM
mat ere tiatias 1bf ma pamit or Some is beam requested,ant the Departmeett of
be TeMmed b the citV Of town �P
Indmtrial A d4cM Should you have 9ny questionsreaodiea the law or i[yaa am ngpued to obtain s woman
compassd=Po&%pkM can me Depsuow st mo number listed below SelFiammed aamp4oim a mm amer mar
self-hwor ma linemen mm ou ON the The
City ar Taws Ofi3dah
iS less and k&b The Dgmrun at hfn provided s spade a<me bottom
plasm be acre mrt tea afildavk aomP Prior
of the afidavk fbr yen b fill nut's the event;ma Office of IavaStigatiom has b cocci you reaatdiag me aPV*sML
Please be sort b in the pamiNlieeeee somber wbich will be used as a refaeoa mmmer, in addition,a applicant
that mart submit makVIC pamaAieme spP��m any Siva yew,need only submit one af%dsvk iodiratimg cmreffi
Pommy hLbrundan(if necanry)sad under"Job She Addrea"ma Sppiiaot should write"all locutions m (city Or
sown}"A copy ofma a®davit that bas been o®eiaW shmpod or maked by me criy a bwa msy be provided b me
applies err podand s valid afiidsvk is am file lift fimne pamie or Hewes. A war affidavit mustbe filled out Bich
year.Wbese a boors owner qi e, , . is obtaining a Scow a no permit n relssed b any business at com mu ciel venture
(it a dog Haase a pem*b ban laves de.)said person is NOT regsaed b compkb dais afiidah
The Office of la veatip tun would hie b mast you in advance for your eoopaatioa and should you bave amY quadon%
please do tact bei"b givens a am
The Department's addres,wlcpbns and fie nomif>r
The Canmonweallik of Musa llusdb
DepatUnCd of&&strial Awdab
O®oa Of InVeS11001111
600 WWW119ton Strad
Boston,MA 02111
TeL p 617-7274900 ext 406 or 1-MMASSAFE
Fax 0 617-727-7749
Revised 5-2" www,mawgov/dia
CITY 00 SALMNS MASSACNYiATTS
PUaUC PROPILIM DCPARTMCUT
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SmSl .MA OI*"
T*L c6701 7464 a IMT. Ras
FAX 16740 740414{A
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