6 ROSLYN ST - BUILDING INSPECTION •. 4
PUBLIC PROPERTY
DEPARTMENT
Kj%WFILEY Dllj$l:uLL
MAYOR 1M WASMNMr.4 VLEET 0 S"LX.K MASSACHLSL-1-S 01970
TM,97e-74S-9S"#FAX 970.740,19"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
ti
Property is located in a; Conservation Area YIN Historic District YIN ->
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: s
Address:
E5, tile. /"7
Telephone: ) - 7-5 I - 7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: t/yw!Cel SL l�� 7�cwSr
Mail Permit to:
What is the current use of the Building?
Material of Building? it dwelling, how many units? y
Will the Building Conform to Law? Asbestos? AJ�
Architect's Name
Address and Phone t
Mechanic's Nams t9r,� s ( �.�Sto��tsv ✓ 7�L
Address and Phone `���/-<cqA'�(.a S 112 I��A�3t i�v �A•��i%o
Consbuctiion Supervisors License# HIC Registration# Lr10 S 7�c
Estimated Cost of Project Permit Fee Calculation
Permit Fee$ I H9,c.o Estimated Cost X$7/311000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury /� V
Date 31,19 0"
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--------- - F Or-- ._ . — _
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tcaaaesleY nancott
MAYON
in WA9W4GYOt1 STRBY a SA1.64 MAMCtn:mrls 0lW0
TE U 9M745.9595 a FAX 978.740981E
Workers' Compensation Insurance Affidavit: Bullders/Contractor$Meetric&nw?lumllen
Applicant Information P!ease PrintLegibly
Name(Buaieeaa/OrgaetitaftemUdividual):�S7n Z LC�� / in, S t/l r �,✓
Address•_ .9, t 1 r m,_14e.9
City/State/Zip: 2`&It ol5�sr r�.n c� n/ n Phone
' I
Are yow as employer?Cheek do appropriate best
1.❑ I am a employer with 4. ❑ I an a Small contractor and IF[0:]ER=odcHng
Project fre9dred):
employees(full and/or part-ume).• have hired the aubconeactors truction
2.❑ I am a sole proprietor or parmer listed on the attached sheet t ng
ship and have no employees These sub•contracters have nworking for me in any capacity. workers'comp,ionuance.[No workers'comp, insurance 5. We are A corporation and its addition
required.) Of ices have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing mpsW or additions
Myself.[No workers'comp. c. 152, §1(4),and we have on
insurance required)t employees.[No workers' 12.❑Roof repairs
comp. insurance requimd.) 110 Other
*AaY WPlkas thr dwcim boa al man won nu sue tea swdm blow dwyAol dmk wade�a'eampaaadea wttaY ht4myea,ltampwbaa wha athds tW,fedavk mdk+tlaa ehay a s dWn$a8 work and thaw bfn ebtalda oaWn emn mu ahmk a saw at)id{Ya
tCoebacton tau cheek tab bas amt mwhad a ad"=al drat rhowtaNREWENEIWW� a Ow nano of tb. and drk workrra•romp 00119y mkrmatlo�a,
an ma employer that U provldlnd workers coaspensatl
Injoratotlow, mi'ow 4arura"0oi employees. Below is the polley and job site
Insurance Company Name:--
Policy N or Self-ins.Lic.tit r2•v r� ,r Expiration Date
Job Site Address:_=E ('o ' P 0 C/S w, S Y
CirylState/Zip.—f.4 Ls-,=, s....•,_c�,Attach a copy of the workers'compenaadon policy declaration page(Showing the polity number and esptncloa 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$1,500.00 and/or one-year imprisonment,as well as civil Penal tics in the form of a STOP WORK ORD ER
and a fine
of up to$250.00 s day against the violator. Be advised that a copy of this statement may be forwarded to the Otlic
Investigations of the DIA for insurance coverage verification. e of
/do hereby catriJj under the p" and lies ojper/wry that the lajornaatfow provided above 4 tewe and eorred
$1Yna1St[e
Da w• 'J �.�1� -c7 7
'
E01her
only. Do not wrlfe G thk area,to be completed by chy or town offleiaL
n: Permit/License N
Authority(circle one):
Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector
son• Phone tl
Information and Instructions
Massachusetts General Laws chapter 152 requites all employers to provide
etvice of�rkeW compensation Yc�u employes.
contact of hire.
Pursuant to this statum an sarpfeYee is defined as ...every person
in the express of implied.oral Or wriu ."
as"an individual,purnership,association.Corporation a other legal entity,nt any two of meta
An carp10Y4 is defined end including the legal reprzsentaaves of a deceased employer.��
of the foregoing engaged in a joint"UrPrParma ise. association a other of the occupant of tla
receiver a trustee of an individual.parttiershrp,
owner of a dwelling boom having
not mote theta three apartments construction a reP�wodt on such dwelling battle
dwelling house of soothes who employs persons�maintenance nagbecause such employment be deemed to be an employer"
of on the grounds a building appurtenant
state er local licaustag"t aey shag withhold the tanaaee nt
MGL chaps iS2.¢25C(6)also states that avert V the cOmessaw"MY for an,
to operate a business or to eosah net�the insurance coverage required-"of its poH&a stibdivisions_
reaewai e a o has not+or p�ed acceptable evWesa of eomptlaaee
age ditiou wMGy chap 152,12=7)states"Neither the commonweahhQ �of compliance with rM
Additinto an. of public work until acceptable insurance
enter into any contract fat the have
bian pre to the contracting authority"
Kquirempats of this chaplet have bean l�n�
Applicants
affidavit eninpietrly,by ebeelans the boxes that apply to your situation and,if
Please fin out the workers'compensation n & ale with their Cettificaa(s)of
s name(&),address(es)and phone umber( )along employe"outer than the
need Limitesupply d Liability t OMPOsies 0=a Limimd Liability n)�no LLP does have
to carry workers'Compensation' of Industrial
members or psrmefs!are nett required that this affidavit may be submitted to the Department
ould
emploYem&policy is require& Be advised
Accidents for confirmation of insurance coverages Abe be sore to sign and sin the affidavit, The affidavit of
be returned to the city or town that the application for the permit a license is being requested'to
the Department
Wrding the law or if you are requited to obtain a workers'
Industrial AcCW=t hose call thav*enDepatmte� nth listed below. Self-i anted Companies should enter their
compensation policy.P
self u simmes license munber on the
City or Tower Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigation has to contact you regarding the applicant
Please be sum to fill in the permiulieense number which will be used as a reference number. In addition,an applicant
lications in any given year,need only submit one affidavit indicating current
that must submit multiple permit/license app
policy information(if necessary)and under"Job Site Addmpe the ap or plicant by�write �may be provided to the
town)."A copy of the atfidevit_that has been officially stampedOut cub
applicants as proof that a valid affidavit is on file for fbnne permits or licenses. A new afZidrvir must be filled vesture
year.Where a home owner or citizen is obtaining a license or permit not related to any business err commercial
(i.e. a dog license of permit to bum leaves etc.)said person is NOT requited to complete this affidavit
questions.
ns would like to thank you in advance for your cooperation and should You have any ]
The Office of investigatio give
es a call
Please do not hesitate to
The Department's address.telephoner TM vies1th of husctts
N"Munt of Inbstnal Aeeicknts
of n of INTUdgadOns
600 washjngtOR SUVd
Boston,MA 02111
Tel. #617-727-4900 W 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.03 WWW.IDMg0V/&
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY )XISCOII.
M[ Yolk 120 WA4IINGTONSPREET ♦SALEM. MASSACHISF1 IS 0197C
To,978-745-9595 4 FAX;978-740-9846
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 of facility)
(address of facility) - -
s nature of permit applicant
3 ' ate 0 7
date
- tic6ri:ai'f.doc