84 ORCHARD ST - BUILDING INSPECTION C�
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? / Asbestos? /
Architect's Name
Address and Phone ( )
Mechanic's Name c n
Address and Phone /1 z'-7 w o d i4 C,
Construction Supervisors License# 6;�/ F 7 HIC Registration#
Estimated Cost of Project$ S 6G. Permit Fee Calculation
a✓`
Permit Fee •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 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 X / / ;,
Date D
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OCIAM
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIA(BERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET♦SALEM,MA.SSACHUSEM 01970
TFL-978-745-9595 ♦ FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A 1 licant Information // F Please/Print Le ibl
14lime (13usirWWorganizationAndividual): r `- Off' Z
Address: ) Z5-/I —
City/State/Zip: 95�1/�� Phone 9:
;5rc you an employer? Check the u�tpropriate box: Type of project(required):
1. am a employer with 4. ❑ )am a general contractor and 1 6. ❑ New construction
employees(Cull and or p n-note).+ have hired the sub-contractors 7. ❑ Remodeling
2.❑ t am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑Building addition
JNo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL I I.❑ Plumbing repairs or addition
}.❑ I ys a homeownero%
ork doing all work � 1152, 1(4), nd we have no
myself.[No workers comp. § 12.❑ Roof repairs
insurance required.]t employees. LNo workers' 13.❑ Other
comp.insurance required.]
-Any appnicnnt that chucks box ill must also till oul the uctian bluw showing iheir workm cumpenwtion pulicy info=tiorc
'1 tomcuwmo who submil this affidavit indiuting Ihey ate doing ail work and then hire outside contraclon moll submil a nov al'Rdavil indicating uich.
-ConimWts that check this box must attached an additional sheel showing the napto of tho subtonaaenon acid their workers'comp.policy informatiun.
I con an employer that is providing workers'compen.sation insurance for my employees. Below is the policy and job.cite
information.
Insurance Company Name: (oi/ r 4
Policv k or Self-ins. Lis,]#: U Expiration Datt: J
Job Site Adli7L'xS: ✓O City/State/Zip:: e 6
Attach a copy of the worker' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well us civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Bc advised that a copy of this statement may be forwarded to the Office of
Intcsligaliuns ul'the DIA for insurance coverage veriticatiun.
l du hereby certify ruule the pains air pe ties pe ury that the information provided above is true and correct.4ie:ruuro: D t
Phone is
Official uab only. Do not write is this area, to be completed by city or town a f/iciaL
City or Town: __._ Permit/License 0—_.__. _.-------. .. --
Issuing Authority(circle one):
I. Iloard of health 2. Building Department 3.City/fown Clerk 4.Electrical Inspector S. Plumbing Inspector
6. Other —
Contact Person: __ Phone p:
i
�. CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBULEY OMSCOLL
,MAYOR 120 WASHINOTON STREEr• SALEM"SMA.SSACHLSE-17S 01970
'IFi 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: 6X 6 F a .S Building:
Property Address:
Property is located in a; Conservation Area Y/N_GG Historic District Y/N Y.Z
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land —r iY e _&I Z-(, 7 S r c c-� '
Name:
Address: �/ 6/ S 7 J-- ,�4 .S
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 New
of existing building
Brief Description of Proposed Work: ellA
e '/'-,;Z--
Mail Permit to: