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5 RIVERWAY RD - BUILDING INSPECTION i �CIT'Y -- PUBLIC PROPERTY DEPARTNIEINT I:I.%WFJtI.EY DR15l:ULL 7 � MAYOR 120 WASHINGTON STREET 1 SAIEY,MAasACHl:ShTIS 01970 TE:978-74S-959S* FAlt:979-740.98" 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: Xl v Pr,--, „4 q )k Building: Property Address: g X\v2 pz w�-L� T�-� Property is located in a; Conservation Area YIN N _Historic District Y/N N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: elm 4 vwrzS IZawt61-D %�v¢rzreiStln� Address: / 5 7Zo w L✓Y�v b T >� c e Telephone: 1 - - 72 21'/ 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 of existing building New Brief Description of Proposed Work- Mail Permit to: F What is the current use of the Building? �/ IN 1,1,(.2 - Material of Building? If dwelling. how many units? Will the Building Conform to Law? `/P�i Asbestos? A�© Architect's Name Address and Phone ( ) Mechanic's Name,— Address and Phone l0 3 l N"a vN 7p4"'`/ YZI> OV Construction Supervisors License# 6 92,83 HIC Registration# /0 7 1;- a,7 Estimated Cost of Pr ject$ a 0 K Permit Fee Calculation Permit Fee $ --�—D Estimated Cost X$7/$1000 Residential 1 �jS J 3 Estimated Cost X$11/$1000 Commercial tAn Additional $5.00 is added as an Administrative e Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit t ove s d specifications. Signed under penalty of perjury X 1,eo� Date 3 7 IN S N O � L 6� d 6 � � o � o o .. Z � m u c0 r> q u O, f � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesilgadons 600 Waskaigton Street /Vivi Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricums/Plumbers Applicant Information --� Please Print I.eeibly tuss Name(Busi orgaaizationtindividual): .J r -P C6YYs t7LUG7?dYll (�O Address: (93 TTZt MOUlllTi4iN City/State/zip: IVonig-Ar7- Yyli4 Pbone#:-76/- 5-91-7677 Are you an employer?Check the appropriate box: Type of project(required): 1.10 I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑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.❑Electrical repairs or additions required.] officers have exercised then 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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.❑Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit radiating they are doing all wort and then hire outside contractors must submit a new affidavit indicating such. tCmtmcoars that check this box must attached an additional sheet showing the name of the sub•coahaotors and their workers'comp.,policy information. I am an en rhryer that Is providing workers'congwitwilon iavurance for my etployem Below Ls the policy and job site Infotrxadon. Insurance Company Name• /�i 5 Policy#or Self ins.Lic.#: (3 - 3/K6 Expiration Date: Job Site Address: 7Z�Vrz7 vv'r1t �f � Cityrst Z : -�I vltl{1 e 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 top to$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$250.00 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. I do hereby fy u the and ofpedury that the inforowdon provided a&o tpie and correct Si Phouq # S/h 7 QQicial use only. Do not write in this area,to be congrleted by city or town ojfk&L City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M. Crry OF SALEM PUBLIC PROPE M DEPAE'i'D INr ,mat eerma Ilk#W464M0 tn.tW4&" Coubmcdoo DArb Okpood AMdawit (vaq�ini mt�diesltdo�d rstwads�wadi is m=Wmos wide ow : s OftCok Ise 00 sedim IMS oebd� b had wb1 ds sse"M mat ow&b k MM1166 6" �y wait.irll tN dt�eW adi��pa�lbr llo�i.rw d1'awt Ae[�gt a�dde.d bar 1i0..• 111e s 15" yn `-7Z L/G L� (aer dbnM� The dells wiB be di;oud odla: 444wl � - (ahk"e,r�ev4» '�bnrTl�/