11 RIVER ST - BUILDING INSPECTION ' PUBLIC PROPERTY c�
DEPARTMENT
KISOFN.6Y DRISCOLL 1
MAYOR 120 WAswNGTom S`mEEr*&"LILK M.AttAcHLsj-k-M 01970 Q
T'M--978-73S-9S9S•FA1t:978Ji0.98"
/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:
if'iV-Y
Property is located in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
[Telephone:
ame:
ddress:
4? 7
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 ? �{1
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building? Qs •�"`�
Material of Building? It If dwelling, how many units? 2
Will the Building Conform to Law? �9� L Asbestos?
Architect's Name
Address and Phone I
Mechanic's Name
Address and Phone
Construction Supervisors License# 030.4 HIC Registration#
Estimated Cost roject$ Permft Fee Calculation
Permit Fee$ 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 build to the above stated
specifications. Signed under penalty of perjury X
Date l v
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Knratatav oaucat
MAYOR uo WAsrv4GrpN smear•
s►Lu .htwlsAaamt-rso197o
TEL WI.745.9595 ♦PAX 97ti•740.9846
Workers' Compensation Insurance Amdavit: Builder/ContractorsmecMclan>t/Plnmbers
ADDUcaut information
p n
Name(Bu"mwoweiadodmdiv;mw)7 1VV 30�)L iJ J 1 L-,>EC S Lt C K o
Address: (D 0 W ('a D-rc- � 7
City/Stateaip--(:�'W Run p u•rr*1 D i 09-- phone#
An you as employer?Check the appropriate boss
I.® I am s employer with 2 4. ❑ I am a general contractor and I '�of project(re9dred).
employes(W and/or part-time).• have hired the sub contra s 6• ❑New construction
2.❑ I am a sole pmpdanar,or parrot listed on the smacked:heat t 7.Q Remodeling
ship and have no employees These wb-conuactora have S.
working for we in any capacity. workea'comp,iasansei . ❑Demolition
[No workers'comp,imauance 5. ❑ We axe a corporation and in 9. Building addition
Ruda officers have mroroised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of wmmprioo par MOL 11.Q Plumbing repairs or additions
myself [No worker'comp a 152, 1(41 and we have no 12.❑Roof:spares
insurance required.]t employees [No workers,have
13.❑Other comR insurance require&
'OAny appaeaaa 60 cheeks beg at now sw sec mw the seotlaa bdoe army their�arkaaa'
xma.o es 60 check
wheal this mac a e the s a tM•en da6aa a8 week and than him��a s
wbrmsdm
reoaa.eta,s thr cheek this bear moq auehad an addidand shm d oema the nuns of the 'Oa,wb�coeoratao and awdr wghas'song t�Y taawaeWaa.
awe an emploper that is provldlnj worttera0 compewadow bwxrance for my employees Below,b Mae polfey and job slur
Information.
Insurance Company Name:
Policy#or Self-ins.Lie.# W l � �P0 3 L.3 /
p Expiration Date: d 7
_- Job Site Address
Attack a copy of the workers'cow City/StatrJZip: n /t
peasadon policy deelarad'sa pegs(showing the policy number and expiration dap),
Failure to secure coverage as 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 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of tie DIA for insurance coverage verification.
l do hereby eerd under she noUles ojper/nry Meat the Injorneadou provided ova l: and carted
C'
00k al use onJA Do not write 1w this area,to be eompletad by c4 or mwa ofJle/aL
City or Town: Permlt/Lkeme#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrieal Inspector S.Plumbing Inspector
6.Other
Contact Person
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requites all employers m Provide anorber under for their employees.
Pursuant to this statute,an employ"is defined as ...every Peronin the service
any contrail of hire.
express or impli4 oral or written."
asaoeiatic4 eorporaticn or°�legal entity.or any two a more
An eatpYoy tr is defmad as"an individual.parmaship, tatives of a deceased employer.or the
m a Dint entaprisa.sail including the legsl t employees: However However the
of the foregoing ati►ti� 1 association a other legal entity.emp Ymi
receives or trustee of an individual.partnership, sd who resides thaein.a the occupant of the
owner of a dwelling house having act more than three apaflt .construction aenta at work an such dwelling housedwelling boutee of another who employs thlacto ersons�oat becanaS of such employment be deemed O be an emploYa--"
or on the gttrunds of building apPutmant
also stave that"every state or West ficWAJng ageecY shut wdtbbeid the Issuance or
MGL chapter 152.$2SQ6) y bugness W to t:onstruct buildings to this eosamsnwadb WW
acceptable a evidence of eomptluea with the lesurance coverage mwre' "
applicant wbe bas not produced
reacewal of a tlaose ens permit to operate a states"Neither the commonwealth ner any of its political subdivisions shall
Additionally.MGL chapter 15p Forman ce of pubes work until acceptable avideoce of compliance with the insurance
enter into; coonva fair the
of this chapter have presented O the connecting authority"
rW
Applieaats if
affidavit completely,by checking the bona that apply m'Yarc situation and.
Pleases fill out the worksub.,eea'compensation
m" with it employees
��cubes than the
necessary.supP1Y s 'COntr O1{s)nama(s),"Wrcss(cs)
Limited
and phone numbers)along p) then ce ploy e s
insurance Limited Liability Companies(LLL7 or Limited Liability lusurance.(I f
to carry Workers'eompensstOn uastuanea• It an ep ore of ��
members s.ppolic i are not reqs require&uired advised that&a affidavit may be submitted to the Department vit should
emplorfor confirmation of inananc°coverage. Also be sue to sup and date the aefldev'L 110 a of
bAccidents e retuned to the city or Own that the application for the permit a lacers f being requested,sat the Department
Indua&W Aeoidenta. Should you have any ques>ans
regarding the law or if you are required m obtain a workers'
compensation policy,p tie Department at the. number listed below. S&-insured companies should enter their
self i l e="II1°°�m the
City or Town Offlelab at the bottom
fete and printed legibly. The Depertaeet has provided a space
Please be sure that the affidavit is comp has O contact you regarding the applicant.
of the affidavit for you O fill out in the event the Office of Investigations
Please be sure O fill in the per"i'Mcnes number which will be used r,n reference number. In a addition, is appg urn
applications is any give year,need only submit one affidavit indicating current
that must submit multiple parniglieere applicant should write"all location in__(city or
policy information(it necessary)and under"Job Site Address" PP the city write
Oven may locations
s in
O the
of tie affW&vit.that has been officially stamped or marked by tY
Own)."A cePY u on file Por tbture permits or licenses. A now afudrvir mug be filled out each
applicant ss proof that a valid affidavit a license a permit not related O any business a commercial venture
year.Where a home owner Of citizen is obtaining NOT required to complete this affidavit.
(i.e. a dog license or permit to bum lava elm.)said paaon
You in advance for your cooperation and should You have any questiona.
wou
The Offiu o4 Tnvegigstions old
like to thank y
please do net hesitate O give n a WL
The Deparnnent's address,telephone a� wUlth of Massachusetts
Deput rent of lndastdd Accident
Oulu M Isvadpdons
600 Wasblag"Shvd
Boston,MA 02111
TeL #617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 WWWMWWLVv/dk
CrrY OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
,4VCS tzsw�o�ar,asssaat.s4n�x.�uaawonsatsrt
Construedom Debris Db"at AM"Vit
(regttieetl ht sll destolidos sod nrtovsotan want)
to a000tdssw with the s6ttlt adidon ddW Shot Hut{dios Codtr 7So CUR section 111.5
p"and*A p mv[siottt aOAGL e44 S A
BnMtei Permit M it tommil with dw condition do dw dsbrit ts=MW hoot
tide wart shsil be disposed oC[s a propeli,I NOWNS d wsstt disposal h d ttlt at dehoed by MM s
1/1.s tson.
TtA debris will be ttaosported byt
—Cq RDa — /colf g C
The debds will be disposed din:
dus
rLmesu or heiliry)
�rosaaatv.mbe�pttiC� ,,
J� > -I-Ad«o
Board of Building Regulations and Standards
_ HOME IMPROVEMENT CONTRACTOR
Registr!HO;;:.1.1 860
Muprutl�8 2008;.
ti+ T.BONE BUILDERR r��- 7,
I TERRANCE JOHNSO't' 1
}F 6 OAKLEDGE RD
{ $WAMSCOTF,MA 01907 Deputy Administrator
BOARD'OF BUILDING REGULATIONS
4,¢ License: CONSTRUCTIONSUPERVISOR,
w Numb4r C3,
Y � BletiM }YLO$I�i79�64. v
4t?xp`i 14J0 l2007_c Tr.no: 89301
iL
TERRANCE L J4HNS0 .,,r a i
EDGER
II 6OAKL
I y SWAMPSC U Commissioner.
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