29 OCEAN AVE - BUILDING INSPECTION (2) ITY-OF L —
"' PUBLIC PROPERTY
DEPARTMENT
Kisal"LEY DIUSCOLL
MAYO{ 170 WAMINGIX +!`�•SAI EU MA15ACKSLI-M 01970
IF1:978-7{i9S9S•FAX97&7a0.98"
APPLIICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Sc-oft G;-Q %^Pr Building:
Property Address:
29 0ce-u in An---e-
Property is located in a; Conservation Area YM Historic Dlstrkt Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: SG VV r ^
Address:
Vey-
Telephone: ( _7 076
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation V Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
bats, aV o-e oto
Mail Permit to:
What is the current use of the Building? �
Material of Building? If dwelling, how many units? T
Will the Building Conform to Law? Asbestos? bn;
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# Lbld& HIC Registration#
Estimated Cost of Project$ . )�b(20 �' Permit Fee Calculation
Permit Fee$ 66 d " Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X 0LA-1
Date 1 z
0
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Y�
Crry OF SAum
PUBLIC PROPERTY
DEPARTME 44T
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Wogs' Compensation Iusu mme Affidavit: NapdeyContru
Applicant Infermadou Plum Print*adbsr
Name jandommadividnew L I
Address:— r, 6 A ✓
City ' _ SW r ro _ p�
gyp' - Pbons#. 7g /—�G
Are you an aspbeyairT Check tke appropriate boss
1.Q 1 as a employer L
�� 4 ❑I am a Swand contractor and I Ty"4f prg4d(
employes(ibB s =).e have hired the w4cooteseent & ❑New construction
2 Oms
le psspatrum Weed as the aeaabed sheet t 7. Q Rasodelbtg
haw no These s hive R Q Demolition
working fa�MINOWs Q Wwaekat.e Am`coma intonate.. y. ❑Bv�s.ddiaa.
toe exercisoratimed
dnd,ee 10.QElectrical
1 oAlesr have esarclssd their repairs or additions
3.0 meowaw doing an wanauca�ork right.f aemptiou pw Mt$. 11.Q Phtmbing�or addidosa
yae (No waken'coma a 152.41(4).and we have no 12.Q
imammet ]t �leYees.(Nowakma' Roa 13.Q
coma insuranceeallukee l
t WHOM dread.bean mat a n now des soaks heir.ebe.tas dedr..d�'
ttaeeeo.us.e.eo�reueredrvrlsdadwgdwY wdeYed.lat.tei.ef.eeerdeesaee,.,s 1Ae r
=Cormeeas dr efe#gels boa sot MOM"a ddldwel ehre d ee ye iy a�of er �101�eaYseeaaaas ed tleek..o.lo.a'mew oollep
am an bpvN�i�erenFas'eowawradoa GerrnwreJN ell,is y�yrp aOAw h**Peflej alJad dN
Laurance Company Name
Policy 0 ar Self-ion Lip.N_ Expiration Date:
Job Site Address
Attseh a copy of tire worker'eomp.tssttbs ponry deelardes pegs(showbg the poBay astsbw sad npkadm dell)6
Failure to secure covengt as required under Section 23A of Ma o. 152 can lead a the impoaiden of aimisat pan,l&&oft
fine up to 31.300.00"War=@'Yew imprisonment ss well as civil penalties in the tam of a STOP WORK ORDER and a Ace
i vesti of up tof230.00 a day a of gainst the violator Be advised Chet a copy of this sdtesu m may be forwarded to the Oflim of gatienu the DIA for infursata coverage veri}Icadoe.
f de hereby cart,& Rehm oJPrysry rhsr ale/w/arsedosi 4 a s..a/eorrKs
Phone_fr ��l / g 6 V 472
o ffdd are oegt a coot wrltr 4 ul6 area,to be csAv ere/Jr cby or M"eAAd
City or Tows: PermlttLleease
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityfrows Clerk 4. Electrical Inspector S.Plumbing Inspector
f<Other
Contact Person: Phase f:
Information ana instructl%juJ
%Ussscbcns Cscwg i Laws chaplet 1 S2 ftad as sN es"pets to pm d fin.come wder°fad at�
pant m this&rearm.an ma's defiIIld ss"••AVeh petiOn 1°the SeNiCA d ttnother under any
express or implied.oral ee
aswdatio4 ootp01don or°�lepl�ft,of my two err mot. ,
as"an iodividuaL pal wash* va ofa decased emplagw.or thi
the(oteioioi in sAn ex*tsJW jaat"W*rW% other let�l a�OWU*elan O However I's
receiver or mates a,so inrl.Wj""morabW attd who resides thateiei.a the ootatpmt tithe
owns dam d me memo inn Paton t oe t�a� oa aei dw heOM
dwailiatl! orbs�� o de Minte"WIN shah not bseausa d sirek empbYeeeet�deemd m b sit employer••
or an the t3oialds or buildiaa sf?PatMi0t
um chow ls%p=0 also tearer that anNrad hdead NCWA"�*0 atuenwes"rW saw
a opens anreratDs "
w �..[w�ir sit�edw 4 � � We�ih neat -- -
_ -Auld accePt" with the inaQ.oes
wftmancs pta of dim the ecoaaerini att�oehYdmee - ---
r
Al�tittsanb ��the boss that ripply�Y'0tle�0°�'� .
pleae f M out the wodte".co> on al �'ou n��(s)aioai with their can kwo)d
accessary. "'bt cappfCWg(s)name(a)6 s&Limited LWH Ity pamerships(�""�no muployew other thaw the
kmaina Limilsd LWA ty Coaip!n►a 10� iamraem 2t an LLC a taduaQiat
n have
me>mbass at
pwuwk an nag
is gs advised that this affi&vk may be submitted to the Dopu=00
9:1101"em a Policy of inanaace coveap. Ale be$we is sip and date the of WIRVIL dd
uanM
Accidents f0could
, he the permit a Nemec is bolas t .
ennued m the oteY a tows that the appNu>fon the law a if yan us required to obtain a wakae
be ustlial A, Shedd yes have sev 4t O0s t nhouW inter tddt
Compensation Doff.p p mtmbee Noted below. Ssli inwted wmpaniee
Belt-irk�e0se m°°berondr
City W TWO Offiddrs at the borrows
Pleas be sure that the affidavit is aompkoa and pritetad leat�h• The Dept�co tpt you tt��`���
of the affidavit for y"m fin out in the event the Office of iaveatip s In addilliM an ggHc of
m Sll in the psm& cenn ntmbsr which will be used a n reference number.
tpleall's be NO hat must submit maitipw perm sDP is my� Y one W davit indieadni eerrsnt
m ear.
policy mfautation(if naccemy)and undo Job Sits Ad&=e the appNaot shotdd wrt town m"all may be
m v(euY as
by the citY Or
town).'A coPY of the affidavit that has been officially> ee I�ieena A a"a&"tdt vit must be MW out atilt
Applicant as prod that a valid affidavit itt an in@ for fbture PMM" not telamd many business a commercial vstusue
yes.Where a bane owner a citizen is obtain,"a s>ie nc ANe is Pam m lets this affidavit
(i.e. a tine Ntxose 09 Permit m buts leave etc.)said pitrson is NOT regcired wmP
s m thank
lit you io advance for ur yo cooperation ad should you have snY 4uestione.
The Office dLivenptio m would fwr a eai
please do not haitam f
ive Ttie DeWW cWa address~m�OAe and fits number•
•lye COmtitoaw"M Ott
Dept Of Iadif*W A=denft
of&*dlavadsROPS
608 wa Wrion sfti t
13asW%MA 02111
TeL #617-7274900 Cd 406 at 1477-MASSAFE
Fu 0 617-727-7749
Uvised 5-26.05 WWW. MM&Ov/d1A