48-50 PRINCE ST - BUILDING INSPECTION EITY-Or&AL —
Q�
PUBLIC PROPERTY
DEPARTMENT
KMIERLEY DRISCOLL
MAYOR /> 12D WASMNG ON 51LEEr•SALEK MA15Ad/LShTl3 01970
14Y:97&745-959S 4 FAx.973-7i095"
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: -Sp ProuceST. Building:
Property Address: SA-m e
\ 011A. lq7 O
property is located in a;Conservation Area YIN /V HistoriC Distrk:t Y/N IV
-------------
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: 2Tc
Address: 4 6- ' c e S 7-'
S q.(.e..i vK,4. Olq7O
Telephone: 9 -) 5- 6S4- 51?o7
3.0 COMPLETE THIS SECTION FOR WORK IN rYlc-rtur. 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:
SI r - P oAce Side S(�+Ye raoF
fe� I ✓t-ce wf >'+Spha ( T 5l�1��c���
Mail Permit to:
What is the current use of the Building? r eS a( euTia 3
Material of Building? w o mod? S ,( If dwelling, how many units? 3
Will the Building Conform to Law? Asbestos? 2.
Architect's Name
Address and Phone ( )
Mechanic's Name 14 C- CAST I-e G C,=
Address and Phone Ptf467,d 4 wrA OIce (, o
Construction Supervisors Ucense# 45g8f32 HIC Registration# I t 7t'lAfo
Estimated Cost of Project$ 48 0 O.-O Permit Fee Calculation
Permit Fee$_61 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
Date !a o
of
�J N
1
130 u ri
- W m - - _ . 5 _ '— --- - ' - --- - ------ - -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
an4sealt,r oatscou
MAYCa IM WAR04GMS UU a IMM4 MAMCMMM019M
Tim 978-745-9595 a FAx:m740.9646
Workers' Compensation Insurance AtHdavit: Banders/Contractorsmectricians/p]nmben
Applicant Information nn Plc n
t Legibly
Name(Busineworpaniratiomi�vidowy H - C. < aa5r(-e c-C -r
Address: 4 2.0t ,
City/State/Zip: - ()-CJ40f Y N<<4- 6196,0 Phone& c? �8 - 740 -5 (40
Are you an employer?Check the appropriate bore
l.,-I am a employer with 4. 01 am a Several contractor and 1 Type New c«t( :
employees M11 and/or partwdme).• have hired the wbconnactasr 6. ❑New construction
2.01 am a sole proprietor or parme[ listed on the attached shoCL t 7. 0 Remodeling
ship and have no employees These anc�oatachors have S. 0 Demolition
working for me in any capacity. workers'comp,insurance, 9. 0 Building addition[No workers'comp insurance 5. 0 We are a corporation and its
required] officers have exercised their 10.0 Electrical repairs or addidons
3.0 I am a homeowner doing all work right of exemption par MOL 11.0 Plumbing repairs or addition
myself.(No workers'comp. a 152,11(41 and we have no
120 Roof repair
c°mp.
' required.]t comp.employees. .
(No workers, 13.�Other %• /r /S,/ fr imutavice required.] o A
t*Any wpm tW chaeb ban e1 amid 4W tan as the secdas WOW daa fi*awe"kee'mmymsdaa pd�Y btbtmattsa ttamaowataa who auhdt fhb afadava [they an"As an wad[sad a,.bhe atWda mabadwa met submh a am stedrvtt bdkades ant&
tCoaaaexma teat ehak fts box mane ana*"m Wadaad And dnw4aa the mma atom F&40mrmam ad drtr wmhm'camp ply btbamulos.
ass an employer that b provldbrl workers'compenradow
injonnaalota lnswraucejof my employees Below is the pollPolicyand foi sfie
Insurance Company Name: A r Pe nrS.
Policy M or Self-ins.Lie.M SJ�4 N3 3S 78 6 7090� Expiredon Date: I f3 C 7
Job Site Address:_ 0-46 Pr,n,c-e-7. Ci /State/Zip: Solent A1,4 r7(g70
ry
Attach a copy of the workers'cam
pensadon policy deelandou Page(showingthe
pogey vnmbQl and a:ptratlou state}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of critninl
fine up to 50.00a d and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK O FX and o penaltiesf fine of up to$250.00 a day against the violamr. Be advised that a copy of this statement may be forwarded to the Ofi4ce of
Investigations of the DIA for insurance coverage verification
f do hereby cardA mnder th/e point and penal perfmty that As Injormadon provided above/s low and coifed
Phone N: - 7 7 ` 0 - r/40
O,Q7eial use onb6 Do not wrAt As the area,to be completed by cky or town oJ]kla(
City or Towv. Permit/Ucense S
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Ciry/fowa Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Penon• Phone p:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employts
pursuant to this statute.an eagWdYn is defined an".-.every person in the service of another under any contrail of Eire,
eXprM of died,oral or written." _
Of other legal entity,or to tw or the
An napfoyer is defined as"an individual,partnership,assacidie le corpontian ves of a deceased employer-
of the foregoing engaged in s joint entespriae,and mehsdrog iha to ees However the
of an individual,partnership.association at other legal entity.employing emp Y
receiver err trustee therein.a the Occupant Of"
owner of a dwelling house having not m' than thisconstruction o do mainUMADCAa repair wort on such dwelling house
dwelling house of another who erurtens t therew s�not because of such employment be wed to be an cmployer.»
or on the grramds or budding appurtenant
MGL chapter 152.12SC(6)also states that"every state or heal scessing agency shag withhold the issuance or
to operate a business or to eomand buildings In the commonweahth for sat
reaswal of a ueeose or perod acceptable
evidence of eompMaaea with the insuranea Coverage required. _
applicant Additionally,o has Sol MGL chapterproduced 1 23C(7)states"Neither the commonwealth nor arty of its pow
subdivisions
enterntoan contrail for the performance of pubes work until acceptable evidence of comp
with the u1surNBOD
inter requirements of this chapter have boon!�°tsd to the contracting suthority
APPFkned
affidavit completely,by eheelting the boxes that apply myour situation and,it
Please fin out the workers' compensstion tea)and phone number(s)along with their cQtificate(s)of
necessary.supply%64ontsaewr(s)namKs). with no employees other than the
Limited Liability Comp!nlef(LLL7 err Limited Liability Partnerships(a)�or LLP does have
are not required to carry workers eompansstian
members a permera. insurance.
employees.•Policy is regttfred Be advised that this affidavit maybe sibs
W the Department of industrial
Accidents for confirmation of insurance coverage' Ake be sues to sip and date the aeffdd,n The Department
should
be returned to the city or town that the application for the permit er license is being requested.not the Depsttmmt
Industrial Accidents. Should you have any quesbi regarding the law or if you am required to obtsin s workers'
at the number listed below. self-insured companies should enter their
compensation PohcY-please can the Depatrnmst line
self ionuance He="mtmber on the
City or Town 091elats
Please be sore that the affidavit is complete and printed legibly. The Department has provided s space at the bottom
of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant
Please be sure to fun in the panmiUiieense number which will be used as a reference number. In addition,an applicant that moat submit multiple permitAicenae al�heations in any given year,need only submit one affidavit indicating current
policy information(if nemsery)and under"Job Site Addrese"the applicant should write"all locstionarovided to in the a
or marked by the city a town may be p
town)."A copy o[the affidavit that has hem officially fi stamped or licenses. A new afudrvK must be filled out each
applicant as proof that a valid affidavit is on file for fbture permits
year. s hie owner a citizen is obtaining s license a Permit not related to any business a commercial venture
(i.e. a dog 1uetrae or Permit to burn leaves etc.)said person is NOT required to complete this affidaviL
ou in advance for your cooperation and should you have any questions"
The Office o[Investigations would lilts to thank y
please do not hesitate to give us a Call.
The Department's address-telephone and fax number:
The COMMOnvit9th of Massachusetts
DepalUfted of hub strid Accidents
Otago of Invadgidona
600 washingft Silent
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 wWWMLASLgov/dig
1
CrrY OF SAtEN<
PUBLIC PROPERTY
DEPART ENT
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