63 PROCTOR ST - BUILDING INSPECTION EITY-OF SALE
PUBLIC PROPERTY
DEPARTMENT
Cll � �fa� �
KIsWFJLLEY DR15L'Ull.
MAYOR �3 l2o WASNINCrnN srmur•SALKK HAAACHMI-IS 01970 TEE,979-74S9S9S* FAX 978-740-98"
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION.
DEMOLITION3 OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: (o - Building:
Property Address: 6S RD A `vT UN lT F
Property is located in a; Conservation Area Y _Historic District YA®
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address:
owT
Telephone: onoo �q5 ( h
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
lariaf Description of Proposed Work:
INSTALLA-�Jor,� OF NFW F(PF-VAE CH IMNEI
——----Mail Permit to: -
What is the current use of the Building? �
Material of Building? WCOh If dwelling. how many units? 1
Will the Building Conform to Law? ��`� Asbestos? i�IO
Architect's Name
Address and Phone ( )
Mechanic's Name C
Address and Phone ✓ G 1(-e S �(
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$--,42-X�0,00 Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.06 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
�P/e it to b lid to th a ve stated
specifications. Signed under penalty of perjury X
Date . :2.--L "l
I
of
4Oi1 � N
a
a
4 ..- - --- -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tustaERsaY nuscou
MAYOR
120 WAslatvGTON STREET a SAI.EN,MASSACHUSETTS 01970
TEL 9M745S9595 a FAa:978.740-98"
Workers' Compensation Insurance Affidavit: Bufiders/Contractorsmech{dammiumhers
Applicant Information Please Print r
egfty
Name(Businessssiorpnira600rtndividual):
Address: 1 I lcso'_� ST
c[ty/state/Zip: WC ( I L1 0eQ PhoneOk 933 IRW
Are you as employer?Check the appr ;
1.❑ I am a employer with 4.713m a genera(cononctm and I Pe of Prol«t(trogaired):
employees(!Wl and/or part-time).• ve hired the sub-contract%s 6• ❑New construction
2.❑ l am a sole proprietor or partner6 ted on the attached sheet t 7. (1 Remodeling
ship and have no employeesese R&VIontractors have S. ❑Demolition
working for me in any capacity. rkers'comp,insurance. 9 Building[No workers' comp.insurance e are a corporation and its ❑ a addition
requited.] OHICO s have exermsed their 10•13 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repair at addition
myself.[No workers'comp. c. 152,j 1(41 and we have no
insurance required]t employees.[No workers' 12.❑Roofrepaio
comp.insurance required l 13.13 Other
;AW Wpm for eheeke boa s1 must ateo 911100 the sac"below showing tltstr tsasirste
=Compass that ahedk this boa must nnectied no sdMoeel s�shorio ��he onadde eoenarten NOW aim a am saWmrY b dko ft reef.
a and dish warko'coma VoKov iof nmdos.
I an an information employer that fs providht;workers,compensation insurance for my emptoyeet Behrw is the pol ky and fob site
Insurance Company Name:
Policy#or Self-ins.Lie.# Expiration Date:
Job Site Address: City/stiuvzip:
Attach a copy of the workers'compensation policy declaration page(showingthe
015cy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of imposition OP WORK criminal DER and o Panwilesf qne
of up to S250.00 a day against the viol". Be advised that A copy of this statement may be forwarded to the Office of
Investigations of the DIA forinsuran overage verification.
In
f do hereby c rtifj�a er the p nahles ojper/ary than the lnJormadow provided above 4 drre and corned
2-7
Phone
Of]7clal ate Only. Do not write 4 this area,to be completed by city or town of)7eleL
City or Town: Permit/Lkense#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Citylrown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massacbusous General Laws chapter 152 requires all employers to provide workers'cot
for their emPihi
pursuant to this statute,an em*yee is defined as"...every person in the service of another under any contract of hirL
express or implied.Oral Or written."
associatie4 eorporatios Of other legal entity.of any two or more
An siePleYer is defined as"an individual,partnership. of a deceased employer.or the
of the foregoing engaged in a joint enterprise,smd inCbidiog the legal representativesa loyeas. However the
association or other legal entity.employing mp
receiver at trustee of an se b not a partnss ership, ehtes sad who resides therein.or the necupaut of the
owner of a dwelling other who employs Psis work em to h dwelling ample house
construction or repair
dwelling bows of anther m al ursinecause of such employment be deemed
or building apptutenant thereto shall not because
or on the grounds the Lsuana Of
-Every stater or legal dessals s�aCy shag wltbYold
MGL chapter 152.425C(6)also states eartha : udum or to eoaatraet buildings is the commoatesithk for say
weed aea�eptable evidence of Camplhtw with the huursece coverage required."_
renewal of a tleeas or permit to 0
appneamt wbe bar not t 152.$25C(7)sum"Neither the commonwealth mot any of its political the imtiratice
Addr into an.MGL chapter performance of lie work until acceptable evidence of Comps with
requirements
��have presented to the contracting audwky."
Applksab
affidavit completely,by checking the boxes that apply tnyewr situation and.
if
please fin out the wsoodwe 0 s),addreae(es)and phone number(MI)along with their certi8atas)of
necessary.supply ability COMPInift(� err Limited Liability Partnerships(LLP)with no employees other thsn the
es have
members Puteo an not required m carry workers'coon ms�°C0' if an LLC or LLP f Mdustrid
members or parsecs, Be advised that this affidavit may be submitted to the Department
�lee ts a policy is H
Accidents confirmation of insurance coverage. Abe be snn to$190 and date the aefidevlt. The affidavit shasld
nod to the c i town that the application for the permit or
be retur keens is being requested,
of
the law or if you are required to obtain a
Industrial Accidents. Should you have any questionsmimber below. Salitinsured companies should enter their
compensation policy.pleas call the Depatnueffi At the
lira
self-insmence license number on the
city or Tows t)mC1216 at the bottom
Please be sure that the affidavit is complete and printed legibly. The Department has provided a spare
of the affidavit for you to fill out in the event the Office of Investigations beer to contact you regarding the applicant
number. bt addition,an applicant
Please be tore to fill in the permi&%cease number which will be used as a reference
licatios in any given year.need only submit one affidavit indicating current
must submit multiple permid►iCens app licant should write"all locations in----(City of
policy information(if necessary)and under"Job Site Addime►hs app the city or town may be provided to the
of the affidavit that has been officially stamped or maciced by tY
town)."A copy is on file for Mure permits or licenses. A new afudrvir moat be filled ewe each
applicant as proof that a vali r c davit or nest related to any business Or commercial venture
year.Where a home owner Or citizen is obtaining s license P lete this affidavit
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to co mP
The Office of Investigatio
ns would litre to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a salt
The Deparmucnt's address6 telephone and fax number
The COMMO Wth Of M"Suh»setta
Department of Ind wWW Ao Wnts
Oda of tsvadpdons
600 Washington Street
Boston,MA 021I t
Tel. #617-n7-4900 CA 406 or 1-877-MASSAFE
Fax#617-w-7749
Rtviscd 5-26-05 WWW.mBS VV/dla