25 OAKLAND - BUILDING INSPECTION 4 CrrY OP Smmi
PUBLIC PBQPEM
DEPARTUMM
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PUBLIC PROPERTY
DEPARTMENT
14.%MFJU.EY DRISI:ULL
MAYOR 170 WASNINGrnN h REEr•SAI VU MACSACHLSLI-M 01970
TEL-978-73S-9S9S 0 FAn 97&740-98"
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: Building:
Property Address:
Property is located in a; Conservation Area YIN Historic District Y/N--J�L—
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land Qao
Name: _
Address:
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:
---- Mail Permit to:
What is the current use of the Building? n
Material of Building? �� — If dwelling, how many units?
Will the Building Conform to Law? \ Asbestos?
Architect's Name �1 .
Address and Phone �,� E k�v i (�� ' ��
Mechanic's Name—�`, \�s
Address and Phone Q s�
Construction Supervisors License# HIC Registration
Estimated Cost of Project Permit Fee Calculation
Permit Fee$ 'O O 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 property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit
�too�'build to the above stated
specifications. Signed under penalty of perjury X �i'1
Date
S p J
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
rnasats,tENISooct
MAYOR t2o WAsic4arortsTaw a sALsK MAzAcn1srm01970
TeL-97t.74S9393 a FAX V3,740.9W
Workers' Compensadon Insurance Affidavit: Buiiders/Contneton/Eleeh{dsma lamben
Anodcaut Information Ply ire Print r emihlo
Name( )' * S oo
Address•— -XIO
City/Statai ip: Phone 0 Lz\& - S 10 - y1 � __1
An you an ampbyerT Chock the appropriate bass FERemodefing
.esyoired):
1.22 I am a employer with !: 4. Q i am a yeoesal contractor and I
employes Ohn and/or part•unso).a have hired the wb.contractowuction
2. 1101 a sole proprietor er pastneo- listed on do anaehed shoat t g
ship and have no employees 'These haw working for me in any capacity. workers'comp,insurance. Building dition
workers,coma insuranp S. 0 We we on and its
qms
exercised their 10.[]Ekchical repairs or additlaos
3.❑ 1 am a homeowner doing all work right of exemption per Mt3L 11.0 Plumbing repairs or addidons
myself.[No workers'comp. c. 152, 41(4),and we have no 12.[3 Roof repaim
ianance required.]t employees[No workers' 13.[3 Other comp'insurance required.)
*Any aeCaom cur dwh boa et moat a m tM out Ha aaedo•bdmr ahoWMa Ati wakam•
Namaowmn who a bade Hie @tildes mdlallo,day rat datsg A Walt ad Am Wo coM aomeauaaasa ad.eit s oar a1114are tcomookea HY ahad<Ab hat moat scathed r addttloWJ sheet s Hr name of H.soh eaotrattoaa and socL
Hair Wakes'camp Whose"
an/am an employer that Is providbtf workers'compsmadow iwartrawcejor my eaapioyees Below 4 the
lAformadow po&7 awllol rite
Insunace Company Name: ,\oar
Policy N or Self-ins Lie M
Expiration Date:
Job Site Addras City/Sta cep:_S A\
a.
Attach a Copy of the workers'coon asatbu d �-pe Po�T «hvatloa page(showleg the potlry number and e:
Failure to secure coven as ph spina dab}
coverage required under Section 23A oP MGL a 132 can lead m the imposition of criminal penalties of a
fine up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Sae of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the OtYfee of
Investigations of the DIA for insurance coverage verification
/do hereby cerdJjr anitr the pains and sigmaturevpew Ojper/wry that the iwjomadow provlltl show L trre and correct
3
Phone M:
FJ3o&i-,d
use only. Do not write in th4 area,to be compk Ud by city or town ofJfele(
s Permlt/Lleems N
hority(circle one):
Health 2.Building Department 3.Cltyfrowo Clerk 4. Electrical Inspector S.Plumbing impactor
son• Phone 0: