6 POND ST - BUILDING INSPECTION EITY OF�ALE� --
PUBLIC PR OPERTY
DEPARTbIF.N
Kl+W FJLLY ORLUX1LL
MAYOR 120 WASMNGT[7N b'sr•sALE,4,w,sAan:sL„s 01970
747.978-745-9S"*FAX 97/-740.9846
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTLNG
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: % Building:
Prop"-Address:---- — — --- --
�rnJt> ST
Property Is located in a: Conservation Area Y/N Historic District Y/N&.1_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: t-klAv-ate Cs-,^L,-•,,�>e1--�
Address: `b L.CCXwoo7
O�-t=2£�..fl N�14 O�g83
Telephone: c14-7g - z_ 8 S
3.0 COMPLETE THIS SECTION FOR WORK IN EXIQTINra BUILDINGS ONLY
Addition Existing
Renovation L-- - Number of Stories Renovated i S�p2
Change in Use New
Demolition Existing
Approximate year of 9 a ® Area per floor (sf) Renovated ppp
construction or renovation \�
of existing building New
Brief Description of Proposed Work: t_oNv5UZZ ,%
—-- Mail Permit to: c`�-'r --
What is the current use of the Building? r— J�irS
Material of Building? `-�� `�"��'` if dwelling. how many units?-2 0
Will the Building Conform to Law?
Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# 5 9 9 HIC Registration#
Estimated Cost of Project S 15 00 O Permit Fee Calculation
Permit Fee$ / o Estimated Cost X$71$1000 Residential
------- .-- Estimated-CostX$Ili$i000
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 to build to the above stated
specifications. Signed under penalty of pedury
l l Date 1 1 110 (0`7
i
C6
L.
0
N •� 1 0� c7 y � s
s Q
F ' CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xsaacat$1r natscou
MAroa tto VA200M W STUU#SAUK MAMCH17WM OiWo
TFi W8.745.9M a FAX W&740.9W
Workers' Compensadon Insurance Affidavit: BnildaWContractorameetr(ctan*Tfumben
Applicant Information
Name(Businessroe�nmviaual): ��QH�i3 CSY�Cs� RAJ
Address• Sao M� S r
Ciry/StawZip: v-� �sr �i•�Boe�/ o�` BSPhone# 9"I8—gsa—��ya
An you an employer?Check the appropriate beer
1.Q I am a employer with 4. Q I am a;meta7and
and I T5 Ps of Project( :
'Is
(fhll and/or pact time).• have hired thctord 6 ❑New construction
2.((fig I am a axle ptoprietar a parser• listed on the aet= 7. ling
ship and have no employees These sub-coe S. Q Demolitim
working for me in any capacity. workers'com , 9.
addidw
[No workers'comp,insurance 3. Q We ate a corp its Q Building
required.] of lr4n have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.Q Plumbing repair a additfom
myself.(No worker'comp, o. 152.§1(41 and we have no
insurance required.]t employees,(No workers' 12.❑Roof repairs
cCmp,insurance ] 13.Q Other
fAly Wilma boa e1 mmt SW tm out she stereo WOW d oWa drlr wakma
Heasawaan who subaak dds atadova mdkodag dry so daby an work and d+m No COW&canuum i Mae
tCou"don that aback dds bat am aftwhad an adMmd*Avg ahowtnd ow mate ofdr aaa.eomartae and daoir woslows'O=V teasy b&wm tl
law��er that is provld/es workers'compensadon b"Wanee for my enp/oyeet Below b-Nb jog,tip f balky and
Insurance Company Name:
Policy#or Self-ins.Lie.# Expiration Data.
Job Site Address Ciry/State/Zip;
Attack A copy of the workers'compensation poilry declaration page(showing the policy number and ex
Failure to secure covers sec expiration dab}
coverage required imprisonment,under Section 25A of MGL a 132 cos(cad lo the(mpoaition otCriminal penalties ofa
fine up to S I,S00a d and/or oseh ear aw. as we If sa civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the viohttor. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify ender the and panaldn of per/ary tkat As Inforwodan provided above Is&w and concern
Simmature�
f1
Phone A
Ofjleial ate only. Do not write bs this area,to be completed by chy or town ohk&l
City or Tows: Permit/L(cenae#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Ciry/1'owa Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person Phone#
Information and Instructions
Massachusene General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute.an employee is defined as"...every person in the service of another undo any contract of hint,
express or implied,ova or written."
�motion or other legal entuy.or any two a mom
An employer isdefined as it i ict ahsal,P the legal eves of a deceased t=PloYa,err the
of the fore�ini engatied in elo�0O hi and lo eon. Howeva the
receiver or uusme of an individual.partnerahtP.association or ether legal entity.emPloymiar ttyaupeet of the
owner oth dwelling
house having not more than three apartments ands ff moth on such dwelling bores
,it on mg boom of another who appurtenant
Persona s al mot because be d�to be an empbya'
or on the gmunda
or building appudenent thereto shall not because of such employment
MGL chapter 152.g2SC(6)else states that"every state or beat lleensing sgeaey shag withhold the Issues"co
bdo"d o a business or to consUmd bundinp in tM commeaw"M for any
neswd of a tle as or P Babb ovWeace of eomponsce wkh the huuranee coverage required.
applicantti who
not chop 152,Q2SC('1)smms"Neither the commonwealth nor any of its Political subdivisions shall
of public work until acceptable evidence of compliance with the insistence
entreqerer contract for the performance of this chapter have him presented to the contracting audsasty."
Applicant
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and,it
Of
necessary.supply sub.conmector(s)=*a),Wdrew(a)and Phone number(s)along P)with
employees s)�than the
insurance. Limited Liabthty ComWnin(LLQ at Limited Liability partnerships(LLl')
m cry workers'Compensation insunneo If an I LC or LLP doer have
members or psrttars,we not required Be advised that this affidavit may be submitted to the Department of Industrial
t en'a POftconfi to Hof insurance coverage. Also be sun t alga and date do atfidavl6 "the aSlds`nt should
Accidents for confirmetioa sot the Department Of
be returned to the city or town that the application for the permit a license is being requeste4 obtain a� '
cocipe ial Accident Shotrkt you have say gYO�e e number
et
the law or if you are requited to
tease call the Department a the number listed below. Sol&insured companies should enter their
Policy,P
eo Pe mpenaanoe lice
act
license number on the
city or Town Otlletad
the affidavit is compete and printed legibly. The Department has provided a space at the bottom
please be sure that one has to contact you regarding the aPPh�
of the affidavit for you to fill out is the event the Office of Investigations
be sure to fill in the per=*VHccnao number which will be used as a reference rumba. In addition.an applicant
Please na in any given year,need only submit one affidavit indicating current
that must submit multiple permit/licenso appltesao
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in c'or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may provided
applicant as proof that a valid affidavit is on fife for tbmm permits or licenses. A now af"-&vit must be filled out each
obtaining a license or permit not related to any business or commercial vesnmm
year.Where a borne owner or citizen is
to burn leaves etc.)said person is NOT required to complete this affidsviL
(i.e. a dog license or Permit
would like to thank you in advance for your cooperation and should you have any question%
The Office Of Tevestigatiod
please do not hesitate to give us a calL
The Departt's addMM telephone and fax numbs
men
The C mmonweaith of 1Nfau tchusetts
Department of bnthisMd Atxidenta
Offs t tf tavesd906112
600 WASN200A street
Boston,MA 02111
TeL #617-727-4900 Wd 406 tx 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2.6.05 wwwxn Vv/die
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