19 RICE ST - BUILDING INSPECTION terry-OF'SAL 1 -
PUBLIC PROPERTY
DEPARTMENT
I:1 6MER11EY o;tACOLL �O
MAYOR 11-0 WASHINGfON STREET SAuslr,WA1SACHl;St1T501970
TFI-,978-745-9595 0 FAx 978-740.99"
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
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: �� L e
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYIRTtiuG 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:
Gc � CN 2� ow5
Mail Permitermit to���� e�f�ws
What is the current use of the Building?
Material of Building? If dwelling, how many units? .
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
e U al$32
Address and Phone 4f5 FD^`a'
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ —7 9 q 3- Permit Fee Calculation
Permit Fee $ Estimated Cost X$7/$1000 Residential
Estimated Cost X$111$1000 Commercial
An Additional $5.00 is added as an
1
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Per ft to build t th ove sta
specifications. Signed under penalty of perjury
Date
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6M WisAd Sim Sbed
Boston,MA 02111
Workers'Compentladon Insurance Ai &AI: BnfldustContndarsWesMdan*Thimben
Apipdcy t bl frmatioa Please Print Legi ft
Name (-�e t l� ULYI 5
Addmas: SII 11 .--o
City/Sta ez* �`t +' t Phone a,
Are you as em er�C thripplroprlate hoax' Type of Project t�dredk
1. Tama I am a with �'7iS 4. � geaaal omtrnesor and I
employe"("nowar pa*d=).* Ls b dW Whzaeasa��oes 6. p new
weled oomtroedoa
2.D I am s sole plopritlor ar panoa6 limed on dratr N&A duet$ 7. 0 -
S*and have so employees Three dab•aoahsclmd bave S. ❑ DemoNce
wwkhls tilrme in=W apei4Y. !".!.omqp.ion 9. addidon
[No wad=*comp,insaaoot s• ❑ We ants s .
o lop Elecoiealrepahs or addidamg
3.❑ I�}bomeownw doing all wwk p#Mt 11.0 Plumbing repsns or addMona
myfelt[No wod u;W co op e. 152,f 1(4W at i�;i�Deltsvdi'bo 12.Q ltootrepahf
imaraseardgtti<ed„]t. r. 13 p Other
comp.MMON" 11
•w,q As Aldo loot 01=0 4W 0 avtttse nodes below iovtoa firwo�s'co1a�1 pft bta>e�tloa
t1la vurtm �crucesa}YatadovitbdiwgeaUlmdobg4oakd0mbpij` abmnamw Me toeh
Womy eetndo cbo*GYboi'omererbWot,ddhtmdebeet•bmbomterneOfftr 1ceoa0 dmiwfim•coup poftWw dm
ItadglswPltreslrerbPro brpwsrdas'eawpsassrfosrbowstre h►gaS%,aft-AdorelrMep ftMdJoiafar
insurance CompwNanw
Policy err or Seigle.L.io. tN Ob'W R�VL57�[t Dace: 1 ��
Job Site Addlesa ( 1 e ( y/g /l{p �Gi l el r.�
Attack a copy atdue workers'Compensation poft dedwatim page(aWwlag the pacy number and expiration date).
Fat7me to docoit oovernoe"required order Saxton 25A of MM t 152 can lead tb mt impositbo ofammai penalties oft
Bat up to 51,50Q00 andicr one-year imprisocnu:4 as was civil pesaid"is dire Som of s STOP WORE ORDER and a fine
of up b$250.00 a day agabu t the vlotslor. Be advised tint a copy of thin stasement may be Sorwded In&a Office of
Iavestigamns of d w DIA for insurance coverage veriBadon.
I dr kdmby PeadA M 000*7 stet Me Infw ralow provUd 6 trse And ternma
Sim Date. 06
phone tq� S '26S ASS
OffleAd mu owbt De mat wd&Gs rbb area,to be eompAmd by co o►bww o,81r"
City or Towns Permlmees se tl
Issuing Authority(drde ones
1.Board of Health 2.Building Department 3.City/I'owo Clerk 4.Electrical Impedor S.Plumbing Inspector
6.Other
Contact persons phase th.
Information and Instructions
is defitrd>d . ..:..e =0 fa oub OfIdiea
�Geaad 1s2 regnaarn ' is�di q[motba under am ooatrad°f fie. .
Passoad>o thra astute. " -
e+P'�ire impltedr mayor writtrest ,
also&*,co*orWm*u&w��'6°r OW two or m" '
An swplrya is&Awd as"aa indtvidud, and ioebdag the lair Qf a deewed aspbm ire om;
of t o foreviia 4 is i jt>ir><mttaprir0. aaodati�or otter ko aft a*k*-Wg ermWecL HUWWCK the
owner of a uum bO°� . not mu an�0 motonall�wlo tam a*areia,or ft ooa °f hours
dtaft bmw Of00"who w4�Ianad0 ma batiooe.o�'�oft� be an WVIOYa"
or on the Womb orbuAft maeta sbaD snot benaow of suet etuploYment
MGL,chapter I i2.425aQ do seta dbat"etay state err tool sewdK meema sbdv wkhYold tbs dw'ste°oe
rmcvrd of a lleeoee or perm*is opavie a btWaaa w to eomMirad beiftp V the f�.
avldeace ateempliaaa wia at mnrmm eoverapa nq
I tQ proem" stater"NCAM tha aommonwealm i1oQ polideat ,nns
�nr
eater into arty cow fur the P °ipubHe we*me aoeeptabla .
vapkQemta of thin chapter bsvebeea pcesmrd to rba 000bat "
aame(sL )
APP ( �,.by g dhabom tW apply U you sin mk if
Please till,opt the woticers oompmwdon a �Pew m�G)�g�rhea cat>9c>m(a)of
• I.iabrligr "Kss)) a I3mited Lidnft Pwu m %*01, )wit no empleyeva oe m am die
we not rOWW to Wry wo*cW conVaimmatim nth If ao L=or UJI don lava
ma required lte advised ra d&a>byR**to to ft Ow�d� .�a�aloold
Accidents ix of i coverage &me is being mqueffI4 wt die Depo=cm of
be returned to tit:city or town to me applied=far tiro P=dt or w err if you are required to obtain a workcm*
��, SbMU ymbme any q�'m r ttw la Self-iasoted oo®prmia should eater their
spelt gl&mcaII the Depsm"atthe mmber.*Wwl,
Sdf-b amrmce litxme number oa the Hon
C"or Tom olddalm
Ineaae be ame that the affidavitit comp kw and printed lgply- The De mUoent hire PmvidOd a space at the bottom
of tle affidavit for You to ffi out in the event the Office of Im�atigations lira tocontxt You rc>���appltcaft
mauler w%&will be wed err a reference number. In addition,an appikOd
Please be we to till 0 the permNHcemc Hcatiom in any given yam.need Only sdbmR one affidavit indicating current
diet mut submit Inewe pamkft=w app
pommy information(if eceasery)md.mder"Job Site Addtea"sae appHeaot sbaalw at ritetu�locations -(CItYto� °r
din towel"A°Dpy ofdbe amdevit dwt bm boa offieieft sw SEA-edby ,A'
When aflldsvit=Abe tiled art eacl
appocam as proof diet a valid affidavit is an file for tfiture Pamm S licCow at permit not rdatod to ew or b venture
year. s borne own* to bran leaves p�is required to Oon p�We affidavit.
(i.e. a dog Hdxmc a p�
The Office of Invesdp wee would flee to shams you in advance for your coopaaaoa and should you bwe any q��
please do not besi0us to give us a cafi.
The Depardmenrs addrrsry tekplone and fin mattes:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oda of Invesdgadorm
600 Washington Street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-2645 www.mass.gov/dia
sCITY OF SALEMI, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STRUCT. 3110 FLOOR
fAllM. MASSACHUSSTTS 01970
FAArOR
fTANLfY USOVIC2. JR. TXLKPHCN[: 97f-745-9f93 EXT. 300
N FAX: 970-740-9649
Salem Bllildlns<De rfn,.nf
Debris DlsRgN ii'nj=
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
T� o debris will be disposed of in:
1��SI L�.��,r.�se-�._o •-�- (Location of F acilitY)
S '
Signature of Applicant
Date