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63 PROCTOR ST - BUILDING INSPECTION (2) Crry OF SALEM PUBLIC p1tom m DEPArnaNT �vo. :sr�s�arf:asar•s�axa.aomr+sa+aa t�ar�ts.br•r,.,na».+w Consumcdom Deed. Dtspaal Affidavit OughwA BAN s.aeq Ya aseos+laesa WI&dw"000 atdw Sfab BWWbg Cok 70 C!I SOWN 111.! o&kd and dw p— fstsas a tUOL a 446 s!4t guru"M b b= dTft dw aee"m dut dw dddsi ww4*m wY wob absfl bo d gpo"d dio a p- bmmd ware ARM&Adft s d@&w br ul L a tl1.StJeA ' TtAddWkgillbG by mod s/0 crrrurr,� ( r alumw The darts will be dlgW"ad'ia: u, ,2 s�ti O/J s/lt- (aaw of AaittM , fadirs.lhrittgr) uva" ippmua/ � i 31/9J.0 '7 . i —— EI'PY-OF SAm — PUBLIC PROPERTY DEPARTMENT Ai%a*ALEY UOLSWU MAYOR 13AWASwN TON NrREET•Surx MASU01lSM—M 01970 TEL 9?8.745.9S"0 FAX 978-740.9846 APPLICATION FOR THE REPA_M RENOVATION, CONSTRUCTION. DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: L Building: Property Address: p1ja r-riot 5 T J ow S S Property is located in a; Conservation Area YIN HWorlo DlsM YIN IV 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: S � LV7/} GUis/l2� TT� Address: 6 3 Pl?dedr{ S p�� r Telephone: 9 Lf'— t— 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 (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: 7XU554�-5 9 �Y f'4e- Mail Permit b �frkc ✓ What is the current use of the Building? ©E7u"P�/T12 Material of Building? WOO n If dwelling. how many units? L Will the Building Conform to Law? Y,�'S Asbestos? d%D Architect's Name )VoiS'/3S �ln2wyrg- eot (2 - Address and Phone Mechanic's Name Address and Phone Construction Supervisors t-icense# 0?1�4 3 S HIC Registration# I yq g 7S' Estimated Cost of Project S � '6� Permit Fee Calculation Permit Fee$ Estimated Cost X$7/51000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 Is added as an Administrative charge. Make sure that all fields are property and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X /C Date 3 0 7 S v b / N w a a y O � ~ 0 ` b 9 0 a ----- — s, F — y-- -- - CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT tcnaEalla,r tntncott MAYOR IM VA80W W STREET.SJUE14 MANAMUMM01970 TEt,M743-9S95 a Fax 9M7e0.9so Workers' Compensation Insurance AfRdavit: Butlduwcontraeteramecuicfansiumben AppReant Information ptN se Legibly�ly Name l ): �nS�� �� 40 S 0 Address: S city/state mp: S A LOW\ M A Phone i{ 9 7e— / i1 V — AN you an employer!Cheek tlu appropriate boss 1.ErI am a employer with�_ 4. ❑ I am a general Contractor and l ��of pro]eet(rognired): employes(hill and/or part-time).• have hired the 6 ❑New emstruetiou 2.❑ I am a sole proprietor or partner• lined on the aaaehed sheet t 7. ❑Remodeling ship anti haw no employees These sub-oonaach=have 8. working far me in any capacity. workers'Comp.insurance. ❑Demolition (No workers' comp.inmanee !. ❑ We am a corporation and its 9. Ong additlon 3.(] required.] officers have eseru:ised chair 10.0 Electrical repair$or addittona I son a homeowner doing aB work right of e:rernpelon per MOL 11.[]plumbing repair$or addldona myself.(No workers,comp. c. 132.11(41 and we have no 12.0 Rwrepair$ insurance required.]t employees.[No workers• com4.insurance required] 13� L/l �LsPl9 2I i NWaoroaosm ribs adek a.A1d Ydw t10 ON�Ae.xtla cow reortea d1*rags'camp s"on patky In4serloa, tCaaesaaea err eha k ddr box mart meebolW so adQt�naapit rh��.adc and err Eke auks aamaemn mess miry a am sf ldMt ka) a MdL des do nose olds tad ink raker$•comp Polley bdbrmseoe, r our am enrphryer that to providhq workers'coaspensadoa fiuuranci or JAY employ injornado& I es Below ir thepo&7 and Job,sip Insurance Company Name:— E7Z! Policy#Of Self-in..Lie.w._ U-6 - o o G Expiration Date. aT 3 G Job SiteAddreaa� 3 pG�o2 S� U � Attach a Copy of the workers'eom nsatlon City/State/Zip�Q Ljyt /Ij f G1q 0 Pe policy declaration page(showy the pogey number and espintionFailure to secure date} fine up to 3 SI 00-00 and/ one-year�N im der Section 25A n as ci a 152 Cm lead to the imposition of criminal panel As of a of up to 5250.00 a des s imprisonment,as wen as civil penalties in the form of a STOP WORK ORDER and a Rne Y iWmt the violamr. Be advised that a copy of tills statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby ceraijA under do pains and pena/dea o/perjwy that the lnjornratlow provided above Is raw and correct hone Q(jlew use onIA Do not write In thb area,to be eoarp/eid by dry or town offlelaL City or Town: PermitAucense N Issuing Authority(circle one): 1. Board of Health 2. Building Department 6.Other 3.City/rows Clerk 4.Electrical Inspector S.Plumbing Inspector Contact Person: Phone p• information and instructions provide workers•compensssns for their tmipioytss Wtassachusctte General Laws chapter 1 S2 teQuires all ampleyee;to rothe services of another under any CO of hire. Putwsst to thu statute.an rNpWw is defined as"•••every person o express at implie4 Oral cc wring asNcWinn.wrporadon or° legal eased.m any two a mow An earPl�is defbted -iII uid►vidual.Paemod;,Winchsding oho legal reprawisnva of a deceased emP m the of the foregsing engaged in&joist aoteepnsd. aesociadoa er other legal entity.emPiOy1°g�1oyea Howevof the receiver m trustee Of an ind►vsdual,Pset>zQah three who raids .or the ooeupsnt hnues owner of s dwelling house�Ytlg wont an such dwefiiag who empi ep patrons conutucttm m rep deemed to be m ntnpisyec' dwelling boas of another theRoomsht�n such employment be m on the gerunds m Wilding apP1t00O'°t MGL chapter 152.4�(6)�O uaca that o� hudd agency�eommonwaW�for reaowaf of a sees"or p• to°O L svidosa o f compass"with the insurance aPnlitic�al�regal loo Shan applicant who has not predneW stator ""the commonwealth not any subdiwsiona 152.$25C(7) Banner with the menramn enter an �chapter for the parkwmance of public o ale evwdenee of comp regs of this chapter ban been presented to the APPaaasb ehecissi the boxes that apply eo Yesn dmadae and, Please fill out the w eosee compensation affidavit caq a deeply.by number(s)along with their carslles*s)ofban the ec Y. eau Limited Liability Comp!nisa(LL er Limited Liability ParosershsW(L L `vs�no eanPbYeea members er plan,are not regslred to carry wmittes co>�aaOn instaaem if an L.L.0 or LLP does have that this affidavit may be submitted to the Department of htdtisevi t� empteyaa+•Pad le iequi:°d. as tar ov�ge, Aloe be snit to sign sad date the affidavit. The stLidavit Of Accidents far wnArmadon of insurance application for the patent air license is being request4 nut the Department be rounned m the city of town sbuhaw end 4nastlo°a rasoTd1es the law m if you are required to obtain a workers' Industrial Arxidenta. Sid you h Daps�°meet Sa00d below. Self-inured companies should"M� compensation policy.plans self-ins reacg li¢mss number on*O City or Two Of'gelsd The ijepart ment has provided a space at the bottom Please be sure that the affidavit is complete and printed legibly licant. to contact you girding�app of the affidavit for you to fill out in iceensee eventthe number which will be used as af Invesdpdons reference number. in addition,an 2WHIc"s Please be on m till in the pw= spplieasons in any given year,need only submit one affidavit indieasna current that must submit multiple P necessary) �°��"Job Site AddreW the applicant should write-all locations is ity of t� policy information(if oieeesssry) been officially stamped or masked by the city or town may provided Lowe)."A copy of the atfidavie_ther has m licenses Anew afa;dxvu must be filled Out each applicant as proof that a valid affidavit is oe file for licefitnse a Permits not related to any business er commercial venture year.Where a home Gwent of cmzen is obtaining a licenser or permit to complete this affidavit. yea s dog license m Permit to burn laves etc.)said person is NOT required you is advance for your Cooperation should you have any questions. The Office of investigations would like to thank y Please do not hesitate to give us s ca1L The Depau enes address.telePhnn°aTM� p Wetlth of Massa chuseltg DeparoaWM of tndnsaial Accidents of ft of Iavadvada" 600 Washingt011 Sftd Boston,MA 02111 TeL #617-727-4900 W 406 cc 1-877-MASSAFE Fax#617-727-7749 Revised 5-26.05 wwwjnssLVv/die JOB /✓ C �� Y / - �/ HOBBS ENDEAVOUR CORPORATION 34 Rockland Street SHEET NO. OF ' Swampscott,Massachusetts 01907 CALCULATED SV DATE L rn.o / 7 781.5\81.2454 978.744.4646 5- P f CHECKED BY DATE / ✓�v JS � ��Q(✓ SCALE ifd� 0 y x;� M1 1 jtSto 5. l �...:,J* CS 1 `;ply , t Ti ✓, 5 aL e r , \ <. j —� r 9 ` . z FiL4NK 0. 0 r �!x r� !�•FL C..^vr1 f ,F../S7`�l S' f o .P c y't yr o"e �'