5 ORANGE ST - BUILDING INSPECTION What is the current use of the Building?
Material of Building? �/ If dwelling, how many units?
Will the Building Conform to Law? / Asbestos? l
Architect's Name
Address and Phone I )
Mechanic's Name
Address and Phone /
Construction Supervisors License# 6�/ ! 7,�_ HIC Registration#
Estimated Cost of Project$ JG6. Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11l$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above st d
specifications. Signed under penalty of perjury
Date D
vl
0
N
0 1 �°
w
a Q a w d
CITY OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
KMBERLEY DR1SCC3LL
MAYOR 120 WA.SHINGTON STREEr•$ALEA4,% S4ACHLSF j-r501970
TEu 978-745-9595 ♦ FAx:978-740-9846
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 Y/N_4/ Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land // $
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 (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
11-�104 C 1� s
Mail Permit to:
v r� SS of y� o
CITY OF SALEM . .
PUBLIC PROPERTY
DEPARTMENT
KISrn ERLEY DRISCOLL
MAYOR
120 WASHINCTON STREET* $AIF+N,MAssAcrtusErls 01970
TEL-978-745-9595 ♦ FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please/Print Le ibl
Name(Businuss/OreanizatiotJindividunl): 1 r 41 // •OQ -7.512f Z G
Address: jZ�,/l cv000/
City/State/Zip: ,,/I/,�—, Phone
Are you an employer?Check the(appropriate box: Type of project(required):
1. am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/or p rt-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t �• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
lNo workers'comp. insurance 5. ❑ We are a corporation and its 10.[3 Electrical repairs or additions
rcquircd.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. LNo workers' 13.❑ Other
comp. insurance required.]
•nay up plicant that checks box tit must also fill out the action to low showing thoir wurkari cumpcnsution pulicy inforwinGon.
Ilomoowncrs who submit this umdavit indicating they are doing all work and then him outside contmaors must submit a new affidavit indicating such.
�Conowlors that uhcck this box must aaaehed an additional sheet showing the name of tho subcontractors and their workers'carp.policy information.
I am on employer that Is providing workers'compensation insurance for my employees. Belmv is the pulicy and job site
is ur .
Insurance Company Vame: e/0a r- 5
y
Policy#or Self-ins. Lic.#: Q ��_ /[ �tS Expiration Date:
Job Site Address;_ a0 _ City/State/Zip: Z'
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.'YIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,us well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Inecsligatiuus ul'the DIA for insurance coverage verification.
I do hereby certify]aide the pains ail pe ties pe ury that the information provided above is true and correct.
Sianowre: D t :
Phone is
Official tub unly. Do not write in this area,to be completed by city or town official,
Cityor,roivn: __... __---- Permit/Liccuse#
Issuing Authority(circle one):
I. ISoard of Ileaith 2. Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other —
Contact Person: ____.___._...__-- Phone#: