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2 PROSPECT AVE - BUILDING INSPECTION --- ' PUBLIC PROPERTY � I DEPARTMENT KImBER EY DRI]L"ULL ✓ MAvoR 12D WASHINGTON SPR ET•3II&hk MASSACHLSLI-M 01970 'hy 978-74S-9595$ FA3L 97&740-9&4 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: Building: Property Address: Z p Y'O S P eG� A-u(f—�7- property is located in a; Conservation Area YIN Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land q Name: vt �v l e—S VA C— —e C S Address: Telephone: — q 7 — 7 3.0 COMPLETE THIS SECTION FOR WORK IN EXIST1NG 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: vv _ r _) 2E p C,6 Me cv[ w e o�t�©c�7 S /l 7 E Doo2S 4 FIZA VA GS 1 U P D A't C- KiTcLAe LA (Zepoa.« S S � 2e���cK (� 141c � eS -------Mail Permit to: What is the current use of the Building? �PCk(114 t Material of Building? in)d C7 If dwelling, how many units? Will the Building Conform to Law? Asbestos? N 0 W L Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# CS (D770'1 �HIC Registration# Estimated Cost of Project$ O0 O Permit Fee Calculation Permit Fee $ 7`�� Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to bull o t above st tbd specifications. Signed under penalty of perjury X Date Z - ! 0 N - 9 Q � • C 0V e CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT anearat$tr nteacou. MAYM 120 WA NMTONSum a UUK B &WxMnJ4tM01970 TM-9n-743-9S95 a FAX 9)11-740.986 Workers' Compensation Insurance Affidavit: Builders/ContractorsMectriciana/Plumbers Applicant Information n a se Print Legibly Name BusiaesVOt�miatiam/InmvidtW):_ 1� t u rn P 1 o I/�� t sots ce C Address: S © C f© Ve v'pl C A v L City/Statelzip:- SA-Ce M IAZ( V+ Pine o 1 -2 7 ff— 76g—�Z�f An you as employer?Check the appropriate boss 1.❑ I am a employer with 4. ❑ I am a Sanwa contractor and I Type of Project(required): loyees(Nu andlor part-time).e have hired the subeonsactm 6. ❑New co°atrucdoa 2 1 seam a sole proprietor or partner- listed on the ataehed sheet, t 7. ❑Remodeling ship and have no employees These�have S. ❑Demolition working for me in any capacity. workers'comp,miuranee. 9. (No workers'comp.insurance 5. ❑ We are a capondon and its ❑ addion re uired o 10.Q ) filcera have Electrical ❑ or 'eXereised their addsions 3.❑ I am a homeowner doing all work right of exemption per MOL 11.13 Plumb or� additions Myself.(No workers'comp, e. 152.61(41 and we have no nP+tte 12. Roof mstuaace required.]t employees.[No workers' ❑ rePain iomaoa 13.❑ � required.] Ot!>or ;ANY wpm test AWN bat 01 now rap fill out the weeks blow sboadaa tmdr woke•Wmpnado,PWIGY _ - .. ttomeotraw rho k dtis box um xa chw=a ebsy W tithes ea wadi sad tb•ebe otrddt emeecssm mutt sdema a ape slddartt rCoeaaemn that chock thb boa moat emceed as additlosr dot sbowka dr rime of as sob.eamiaYan ad emir waters'comp,NOW ktenotI . /ant aw employer that b provWns workers compeade ewreaca forsylwformao . - - eatpto eat Be%w Is Affgooey andfolsite Insurance Company Name: Policy N or Self-ins.Lie. tk Expiration Date: Job Site Address: City/StaW74p: Attach A copy of the workers'compensation policy declaration page(showing the policy number and expiration Failure to secure oven as dates lie required under Section 25A of MGL a 152 can lead to the imposition of criminal Penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 32S0.00 a day against the violator. 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 eerti&an r paLts and that the information provided above is tens and correct Phone A 7 F6.0ther e ono% Do not write 4 r*b area,to be eompkW by chy or town opkill wn: Permit/Licease N thority(circle one): f Health 2.Building Department 3.CRY/Tows Clerk 4. Electrical Inspector S.Plumbing Inspector rson• Phone 0: Information and Instructions on for their massachuserts General Laws chapter 152 requires idcontract of all employers to Prove workers' compensati �� Pursuant to this statute,an exWUY"is defined a-...every person in the service of another under any express or implied,oral or wrtne6" astoeiatios,corporation or other legal entity.or any two as more An eatp/syer is defined as"an individual,pa washtP, nova of a deceased emPlOYM or this of the foregoing engaged in a joint crurprise,and including this legal repraea � � However the association or other legal entity.emPlGyini emP Y receiver or trusts of an individual.of time der and who resides therein,or this OOoupant of this owner of a dwelling 1►ouss havini not mere than throe spartmence rsons to do maintenance.eonsonscti�or woh m such dwelling bouts dweft9 boas of another who tnnplisYs thereto sshaan not because of such employment be deemed to be an UVIOYa. or on the grounds or building appurtenant that"every state or beat accsaing agesey spar wlthboW this Wuasee or MGL chapter fie g or pe also states V tbs eommoswaltb for ate ressswal of a reeea or perstt q operate a business or q eosuAraer ibis krsursnee eoren>a rMahW a 1leaM wbe boa not produced acceptable evWesa of eomptlasee sheer d ,MGL chapter 152,$25g7)states"Neither the commonwealth not any of ice Pow subdivision Additionally, of public work until acceptable evidence of COMP with the inattranca far performance " enter into any f this ct to the contracting authority �this have been presented requirements chapter APplleasb checking the boxy that apply to Your situation and,if Pleases S11 out the workers' compensation affidavit completely.by number(s) ��with their catificatc(a)of necessary.supply s+�OnO�Or(s)ems)'add Liability Patmerships(LLp)with no employees other than the or Limited instuance. Limited Liability Compsniea� off,compensation insurance. if an LLC or LLP doer have members er parooas,are not required y w sed that this affidavit maybe submitted to the Department of Industrial empty,a.a policy is required co, Aire be sure to sip and date the affidavlL The affidavit should of insurance ie of Accidence t the city or n that the application for the permit a license is being requested,�obce� wOrkara' be returned to ry law or if you are required to Industrial Accidence. Should you have enY menti59 t regarding this Y hcy,pkssse call the Department ss the number listed below. Salt-insured wmpaniaa should eater their compensation Po self-insurance license number on the City or TowI1,02klsle complete and printed legibly. The Department has provided a space at the bottom Please be sure that the affidavit is comp once has to contact you regarding the applicant. davit for you to fill out in the event the Office of investigati In additio4 an applicant the be Y reference number. of number which will be used ss a dugplea"be sure it fill in the perru licadon in any given year,need only submit one affidavit indicating current app or le city that must submit multiple permNhcente applicant should write-all locations in­—I city inforMation(if necessary)and under Jab Site stamped the app the city a town may be provided to the town)."A copy of the afHdavit_that has been officially stamped or marked by ry roof that a vslid'affrdavit is on file for fimrs permits or licenses. A new af"-&vit mast be filled Out aeb applicant ss p a license or permit not related to any business Of commercial venture Yen.Where a home owner or citizen is obtaining to complete this affidavit (i.e. a dog license or permit to burn leaves etc.)said person is NOT required you in advance got your cooperation and should you have any questions. The Office of Invesdgatio QwouW to thank y please do not hesitate to give The Department's address,telephone and fax numbs: The COMMOnwe dth of Mmach»setts Depubnent of Industrial Accidents Oft*dInvatiptlens 600 WL*npon Street Bosto%MA 02111 Tel. #617-7274900 eA 406 or 1-977-MASSAFE Fax M 617-727-7749 Revised 5-2"5 wW•mMg0V/&& Crry OF SaLEM PUBLIC pstop m DEPAWLU NT , a,GrrooIL �. ,a�.�Gt,rstaoras,sa4s„oa�,e0t+as Coas&ucdos DArb Dbpud ABldsvit ("wind ttr e.oelWoa.ed tr,rwtltes Woo d a000ataoos wed eh��:+a►�s s�Hai1d<a�Cady 7te c'at�ttt.! �i it boss Veda ar ooe"m dart do dsbb:wlde�etas wok da bo dgpo"Geis,pGOot r ttoaW.raeb dtgad hd t as Mad by tad!L s ut.s tart. 'Leo debts grin b•MmWo bee C Z /?C��oSRC Cs ��'11 �vr CLYn�N) Tim debts will be digoW Otis: / (see of tioiWsa . fyldrew of b+uM of pOe�f�pylkaet � , W 1 F ]�#}' °TiFe Pa�ansau,�eolr/ o�✓l�ama�/uuetla �7 ? BOARD OF BUILDING REGULATIONS ieense: CONSTRUCTION SUPERVISOR' rr.. Number:rCS\ 077099� Birthdate 0110 1964g Expires01lO6/3006. Tr.no: 13818 ��r Restncted�00 999 ANGELOC 1%EIMETEA5� 1�` ______ 1231/2BOST ;, -``' Administrator