18 PUTNAM ST - BUILDING INSPECTION CITY (.-)FSALF'—NT
PUBLIC 'PROP EFUY
D EEP AR JIVIE-- IT
IN)W',mw; I
TM,9-18.745-9595 I 1 978-73;'')tt I,
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STR UCTURES FXCEPT I AND 2 FAMIL Y D WEI,LINGS
IMPORTAN"I':Applicants must complete till items on this page
SITE INFORMATION
Location Name Buildinit,- 07/ 1(1-,Al-
property Address 779 Pi—e'FA-A-Ai J
Map 4
Located in: Conservation Area Y/N Historic district Y/N
Use Groups
(check one)
Residential (3 or more Units) R2
Type of improvement Residential (hotel/inowl W
(check one) Assembly(churches) Al
New ffilildinai/'-� Assembly(nightclubs etc) A2
Addition Assembly(restaurants,recreation) A3
Alteration Business B
Repair/Replacement Educational E
Demolition— Factory(moderate hazard) FF—
tMoveiRclocatc Factory(low hazard)
Foundation Only High Hazard
Accessory Building-, hmitutional (residential care)
Other(cicscribc) Institutional (inclipLeitated) 12
Institutional(restrained) 13
Mercantile ll/I
Storage(moderate hazard) SI
Storage(low hazard) S2—
()WNFjtSIIIp 'MN(Please type or Print Clearly)
OWNFR Name ke- Alp elk P-0 �ePJie-A-6—
Address' . 13 R0LrPv-/ x'- S-'JV fl?"nsl 0,
Telephotic
Dr—SCRIPT
ESTIMATED CONSTRUCTION COST
A
NOTES -
MIECEIPT
_
RECEIVED FROM 6667=yJ 9'nti�0 )�1--< ��
ADDRESS
FORWE
BY -
02001 FORM® LB18 ..:�"
CONTRACTOR INFORMATION
Name 67"//? C 4/r f A"o -
Address 5 r �Abl�ig
Telephone 7 P/ 71e 6 YC
Construction Supervisor's Lic # (�S
Home Improvement Contractor# -*7 /Z
ARCHI'rF.CT/ENCINEER INFORMATION
Name
j Address
I! Telephone
Mass. Registration #
PERMIT PEE CALCULATION �! �'O
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS &�LLi°�I Al C/� �D Ale- zy4l, % � cY �✓�-/.11&FP//L )A- /O t!/
1A,4 S /r zz C O f✓t /Jlt I-P6
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjur
Signed 65/i��aor�u `—
Date e
fo
i
CITY OF SM E:NI, 1UNSSACHUSETTS
BUILDING DEPARTSCUSIT
• 120 WASHINGTON STREET, S'a FLOOR
TE1- (978) 745-9595
FAX(978) 740-99"
KIMBERIEY DRISCOLL
MAYOR T HOMAS ST.PIFRRs
DIRECTOR OF PUBLIC PROPERTY/BLUX)MG CO%L%USSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information ! Please Print Legibly
Name(auaim%s:organizatiorvinndividual): p� A/k/� c ySAIZ�0 .77
Address: l r l rJ� `a(S r zza!/ l /
City/State/Zip: G'f/��S'�F'o�D )WA' Phone#: L Op l 7 /
!` d
Are you an employer?Check the appropriate box: Ty
pe u roJect(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. New construction
— 501ployces(full and/or part-time).* have hired the sub-contractors
2 1 am a snle pmprietnr nr partner- listed on the attached sheet.S 7• ❑Remodeling
ship and have no c llpluycea These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.0Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself[No workers'comp. c. 152,§1(4).and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers' 13,C]Other
comp. insurance required.)
Any applicam that duadts box of must also lilt out the section bclowshowing theirworken'compensation policy miurmatim.
t 11mmown is who submit this affidavit indicating they are doing all work and then hire outside comma s must submit a nco,affidavit indicating such
'r mmto.aon that cheek this box mug ruched an Wi itierml'heet showing that name of rho aub-contractors and their workers'comp.paltry inf itnmtion.
I am an employer the:it providing workers'compensation insurance for my employees. Below Is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
I do hereby cent rder the pains and pen airier ofperjuty that t u information provided above its tr a and correct
Si=cure• >�N `T (�� C> Date
Phonc 9 W L � r3
Official use only. Do nor write in this area,to be cu apleted by city or town official
City or Town: Permit/Llcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing inspector
6.Other
Contact Person: _ _ Phone#:
l
.1
CITY OF SALEM, iNLxSSACHL'SETrs
BUILDWG DEPARTMENT
a 130 WASHNGTON STREET.3' FLOOR
d� TEL (978) 745-9595
FAX(978) 740-9W
KI.NIBERLEY DRISCOLL
MAYOR Tl oNw ST.Pw-m
DIRECTOR OF PUBLIC PROPERTY/BCIIS)L*IG CO\L\IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name f tacil6 ity)
(address of facility)
signature of permit applicant
date
,.t�ndwira,w