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188 NORTH ST - BUILDING INSPECTION EIS Y-OF-S L PUBLIC PROPERTY DEPARTMENT Kl.%MF U"13115COLL MAYOR 120 WASHING"S-MEEr•SALE MASSACHM-TIS 01970 'I4L 978-745-9S9S•FAY:97&740-98" APPLICATION FOR THE REPA_HL RENOVATION, CONSTRUCTION. 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 YIN Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: f7/QR Al Address: Telephone: l-`f - 3 3 5 -1?5-1 3.0 COMPLETE THIS SECTION FOR WORK IN OfISTING BUILDINGS ONLY Addition Existing s�G Renovation Number of Stories Renovated Change in Use L New Demolition �� ExistingFG- Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New add Description of Proposed Work: �117J yet Mail Permit to: What is the current use of the Building? R e.5 Material of Building? Pl.s -eL If dwelling, how many units? Will the Building Conform to Law? . Yes Asbestos? 'tio Architect's Name Address and Phone ( ) Mechanic's Name CKIML �LMM CS 0%-+ Address and Phone Construction Supervisors License# C S OR74':1--3 HIC Registration# Estimated Cost of Project$� o© Permit Fee Calculation Permit Fee$A b} Estimated Cost X$7/$1000 Residential Estimated Cost X$1141000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to(thh\e above stated specifications. Signed under penalty of perjury X v" Date 1" 0 a a G \a g+ b u 3� •"p 4 O C r 4 CmOFSUmm PUBLIC PROPERTY DEPARTIRNT '� uar�.oar,Rs�amai.sna�x...o.wa+smw. 1Ut9MI464M 6 PAS M»Nw Cautrncdoa Debris Dlgm#A Atl ult (cequicad Att ar daaooitdas and easovados� In a000WWM wit dw"Widwo(dwStMe BuDdIMCWk 780 Cldf wedas 1113 to taood wit do eoodillom due do ddsk nmd&$AM thk wah dell be dlapowd of is a p "llb SO="WNW dtapad hdtttlt as dsdm d by MGL s 1l1.SIS" The did ria wiu be banapodad by I ��rChvI P �arr • InIC. (am d nw debda will be disposed al in: 36 1A�� 1 MPs i>k� (aama d tAgm )I,�AfQ COT�T 2�. Srd" �r.zw.alpamia� dew ;CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT rntagataYtmacott atl►YOl 120 VA51@eG M S=W a SAtrss,MA$AQaMM 01WO Tnt:9W43-""a FAX:974740.10M Workers' Compemadon Insurance ARtdavit: Bni]deryContraetora/EI ftftWaadPWznbm AnoUeant Intormadon Man Pv nt Legibly Name( >: C(f l 1 N RL �c I i1 tSl� Address: �q les/40R9 5� t cityist t rap: 21-cM U 0 Phone* Ate you an empioyar?Cheek the appropriate bon 1.❑ 1 am a employer with 4. 13 I am A gnat contractor sod I IL I of project(r°9ion entployw(lirn"or pass-tune" have hired the subcontractor ❑New construction 2.®'tam a sole proprietor or partner- listed on the attached sheet t 7. Rssmodelmg ship and have no employees These haw 8. ®�emolitics working forma in any capacity. workers'comp iunuaoee q, ❑Building addition 'comp,insurance 3. ❑ We am a on and its exercised their 10.1 3 Electrical repairs or addidow 3.❑ I am a homeowner doing an work right of m ompdon par MGL 11.0 Plumbing repairs or additions myseti[No workers'comp, a. 132.41(4),and we have no 12.[3 Roof repairs metsence required.]t employees.[No workers' 13.[3 Otho camp insurance required] ;Ar appilsow drr aMeb ban e1 unit an tm as do"onion isdow Showing drlr weSlSee'esepeeSetloa paMr fohnoo too. Haneownesw4e shalt ddo atadevit bfleeens dry a doing as wo*d Am hie aSeSlds aaaeeese ens cetera•es etIIdwit hdbttlsa mo•. rCoetraelae due shook rate bas most atasMd a ddi nod Shea Showinmoommommommom� g She ones of do Wbeentreaae andg ain weber'cmiP pagaY iebmetlaa f ens am MAYAN`that bpwvhft texas'eowOeatadoe LoswaweofOr my exPlOYees Below Isdb poft and joi rAw I Insurance Company Name Q QAf 1n501RAhCk Policy s or Self-ins.Lie.M:-S/ W+ Expiration Date: Q 4 f Job Site AddrasIU(1�I City/Stste/zip:S M R 01�1 0 Attach A copy of the workers'compensation poiley,deeleratien.page(showing the polky number and npiradoa date). Failure to am=covangg as required under section 25A of MGL C. 132 can lead to the imposition of crivaintl penalda of a fine up to 31.500.00 and/or one-year imprisonment,as weg as civil penalties in the form of A STOP WORK ORDER end a fins of up to$230.00 a day against the violator. Be advised that A copy of this statement may be forwarded to the Men of Investigations of the DIA for im iraoce coverage vard iestioa. f Jo hereby the Pala+molt penalties ojPgdmy dial rho ixfm=odoa provAft/ {aitrra awf coerce Signature: Phone Ah OVIClal we onlp of not write in nub area,to be taep/eW by rby ortowa oQfeAaL City or Town: Permialeense p Issuing Authority(circle one): 1. Board of Heslth 2.Building Department 3.Cityfrown Clark 4.Eleetrical Inspector S.Plumbing Inspector b Other Contact Person: Phone M: Information and Instiuctlu i Maasachuseas General Law+chaptaria defieed seas".•+vaY p+�nn is service of another MY their d ofb connaet of ate• Pursuant to I,&satntb.an express a implied.oral at wrtttes." a other legal ectity.or any two or mar An sarploy+►is d+fi0ed -'°individual.parmme+dP. oration of a deceased employer.or the of the foregoing eng+a�is a�omt a tithe legal entity.employin{+�°yw However the retaive a tcastea of m individud.p+rmashtpi who reside+thaeit%or the occup"of" owns of a dwdila{boats having Oot mars rhea mainttmaoa. a repair%WA m such dwelliu{homn d1111e�hottaa of smthsc rho employs tha:eea shall oat because otsuch employment be deemed to be m employer. or on the gta"a building+ppatboant MGL e6+poar 192.12=6)alao Mats that"evary sate w local Scessl t{agemy the wabhhb tb bsrass@ car is oparaq a Walsall a a construct buBdbW rMweaft W saw ress"of a Naw or psrzalt � esisptlsw colt♦the iawnw_ >hafi ast whe hit net preload aaapt+hl+ Ncidoscommonweabbnor itsntbdividow repAdd ,my O chapter 152.125q7)� m " work until acceptable av►deoce of compliance with tat man:ama public fbr the enter into otdds chapter,have bees presented to to contracting vAoft•" Applicants aH(davit co�idly.by�iOng the boat'that apply to Yw situation cad.if pies"till out the wodrm+ enmPa"'lO° . wdh their ardfieam(+)of than the necessary.supp1l! ')name(+].addax aKed)Limit and phom ted Liability oga(LLn with no ampbY+n+ i�aW, limited Liability Coo>p!n es(� iy� N an LLC a LLIP doe.haw members me not required carry of hadoaai+l employem a is t�`ed so'dvind dot this affidavit may aubmisad to the Department Abe bar aaieh tr SIP and date the affkJa mt The ggldsvit should Department Accidents for contkm+tian oi+n+ea°QOwP fan the p�a liana is beat{rcqu�d. of be returned to the city or town dot do applicafmiai AccidentL Should you have any 9�0Os the lawd b a if you an me i co to obtain a woelcers'__ ,—_ „ compensation Policy.plow do° °'tiamd below. Belt-3oaued mmtap+nia should 0°M self- Hgonse number on the City ar Tewn Of>Jelsb ha a space at the bottom Please be sere that the affidavit is compleb sod printed legibly. The Department pmvtded of the affidavit for you a till out in the event the Office of investigations has to contact you regarding the appiicamt number which will be used as a reference number. in addition.an'WHOM Pieaae be aun b fill in the pemiNicena applications w c say�m year.need only submit oat affidavit indicating current that must submit=dtipie p+�icgoo parley information(if necessary)and under Job Site Address'the applicant should write"aU locations is___(trey a or marked by the city a town may be provided b the town)."A copy of the affidavit that has been otfleeeIIY urn peril a licensee. A new aM&vir must be MW out each appticent as prod that a valid affidsvit is on file fa 8retxe Pub i not related to any buainae a commercial venNtr yeas.When a ham owner a°rural is obtaining license at NOT required to complete this affidavit. (i.a. ado{lieew a petnit a bins laves eb.)said parson is ins would like to thank you in advance for your cooparguon and should you have any queswn+• The Office of invesdgutio please do not heaitab to give us s calL The Depar=cW$address6 telephone and fax number. The CpiblpppVYt: AO(Munehusel" Dqut meffi of b&UWd A=deats Of&*dtavesdpdoas 600 WL*09"Sflt d Hatton,MA 02111 Tel. #617-7274900 ettt 406 Of 1-877-MASSAFB Fax 0 617-727-7749 Pavised 5-26.05 wwwinass gov/dia